At a community event in Des Moines, Iowa, Hillary shared her vision for how we can make the Affordable Care Act work for all Americans by bringing down out-of-pocket health care costs.

I’m delighted to be here. I want to thank Dionna for introducing me and congratulate her for now being a member of the Des Moines school board.

I want to also thank Eric Van Dorin, the principal of Moulton Elementary School, who is hosting us here, and his family.

I want to recognize Attorney General Tom Miller. Thank you so much for being here, Attorney General.

And we’re in the district of Ako Abdul-Samad, state representative. Thank you so much.

And we have a number of other elected officials here from Des Moines, from Pope County, and indeed from other places in the state.

I want to start by making some remarks, and then I want to have a chance to take questions, because I hope we will be able to cover one of the issues that I will start with that is so important about the rising cost of drugs, and we’ll be able to get to other questions that you have.

You know, I started this campaign with the firm conviction that we needed once again to renew the basic bargain in America. We needed to tell people and deliver on the promise that if you work hard and you do your part, you should be able to get ahead and stay ahead.

And for me I am very grateful that we came out of the worst financial crisis since the Great Depression. I think the extraordinary burdens that families had to deal with, many of you went through it, combined with the leadership of President Obama, who does not get enough credit for getting us out of that financial ditch we were in, really puts us in a good position for the future, as long as we make the right decision about who should be in the White House come January 2017.

You know, corporate profits are near record highs, but most paychecks have barely budged. Costs for everything from child care to college are rising faster than wages.

So the centerpiece of my economic plan is to get incomes rising again, get more money in your paychecks, give the middle class a raise so that you can get back to planning for the future and providing for your children. So I’m laying out my approach toward this. And some of you I know, I’ve talked with, you’ve been following it.

But I also want you to know that I’m going to pay attention to those problems that also keep you up at night, the kinds of problems you talk about around the kitchen table.

As I’ve traveled across Iowa, I’ve heard from veterans who aren’t getting the health care they need and whose buddies aren’t either.

I’ve heard from teachers whose students come to school hungry, and don’t really have the attention to be able to learn.

I’ve heard from grandmothers whose own children are struggling with drug addiction, so they’re taking care of their grandchildren.

A few days ago in New Hampshire, I spoke with a man whose mother has Alzheimer’s. He can’t afford a full-time caregiver. He has to work. He doesn’t know what to do. So I’ll tell you what he does, he brings his 84-year-old mother to work with him so he can keep an eye on her.

These are the kinds of challenges that people are talking to me about. So I want to be the president who takes on those big issues in the headlines, what are we going to do about Syrian refugees, what are we going to do about climate change—we’ve got to get busy combating it—what are we going to do about the kind of challenges we face around the globe, but also those quieter problems.

And one area that I’ve heard so much about is what we will do to make sure that the Affordable Care Act works for everybody.

You may remember that when I was First Lady, I fought for health care reform. I believed then what I believe now, that every American deserves quality, affordable health care. It can mean the difference between a family being financially secure or going bankrupt. It can also literally be the difference between life and death.

And, you know, health care is a huge part of our economy. So we want to make sure that it’s helping us grow, not holding us back.

The health care battles of the ’90s were pretty brutal. At their time, the insurance companies and their allies in Congress blocked us from making the kind of comprehensive reform America needed.

But we kept at it. I worked with leaders on both sides of the aisle to create the Children’s Health Insurance Program that now covers 8 million children across the country, who get health care they need and deserve.

And I was thrilled to be a member of President Obama’s administration when he signed the Affordable Care Act into law.

And I am convinced that we are seeing the results. For the first time in 50 years, the rate of uninsured Americans has fallen below 10 percent. As of today, we know nearly 18 million people have gotten health insurance through the Affordable Care Act. And despite what you hear from the other side of the aisle, it has not bankrupted America. In fact, it is saving us money. Overall health care costs are going down.

But, you know, despite all the evidence, every single Republican candidate for President has vowed that, if elected, they’d get rid of the Affordable Care Act. And Republicans in Congress have already tried to do that. They have voted 54 times to repeal the Affordable Care Act.

I love it, because it reminds me of that old quote, you know, the definition of insanity is doing the same thing over and over again and expecting a different result. Well, apparently they’re going to keep voting to repeal it. They’re living in what I like to call an “evidence-free zone.” It doesn’t matter what the facts are, they are partisan ideologues, and they’re going to keep trying to tear it up and force us back into a debate about health care.

Well, politics can be, unfortunately, a pretty cynical business, but this really goes further than I can tolerate. I don’t know what they would say to all the people who have benefited from the Affordable Care Act. It’s given millions of families peace of mind. It protects millions of people with pre-existing conditions. It says women cannot be charged more for health care just because we are women. And it lets young people stay on your parents’ plans until the age of 26, so that you can get the health care you need. And I particularly love that it’s given access to so many Americans access to life-saving preventive care like mammograms and vaccinations and blood pressure screenings.

So the Republicans are just dead set on repealing it. And besides, they never will tell you what they would do. So I believe we can basically discount what they say about the Affordable Care Act or about health care. They’ve even said they want to “phase out” Medicare. Imagine that. Well, I can tell you I will never let anyone phase out Medicare, and I will defend the Affordable Care Act.

But as president I want to go further. I want to strengthen the Affordable Care Act, because the truth is, it couldn’t and it didn’t solve all of our problems. Yes, the uninsured rate is the lowest in decades, but the cost of prescription drugs went up by over 12 percent last year. Now, your income I bet didn’t go up by over 12 percent. Meanwhile, other out-of-pocket costs are growing, too. And the insurance companies just keep raising premiums.

So while the overall growth in health care spending has slowed, and that’s good news for our economy. For a lot of families it doesn’t feel like health care costs are coming under control, because their own out-of-pocket costs keep climbing and their wages aren’t keeping up.

And that puts a lot of pressure on the families that are talking to me. And it’s not like you can stop buying the medicine your child needs or skip an appointment when you’re really sick because you can’t afford the co-pay. You find the money, even if it means taking on more credit card debt, or being late with other bills. And those aren’t real solutions. So I think we can do better.

I want us to take a really hard look about the pieces of the Affordable Care Act that need improvement. I have a plan to help families by bringing down the out-of-pocket health care costs that I will be rolling out in the next few days.

Now, though, I want to talk with you about how we can rein in the cost of prescription drugs.

Let me start by saying we live in a time of extraordinary breakthroughs in the fight against disease, from rheumatoid arthritis to multiple sclerosis to cancer. New drugs are making it possible for people to lead healthy, pain-free lives.

And our pharmaceutical and biotechnology industries deserve credit for that. They are helping save lives and ensure that America remains the world’s innovation superpower. And I saw that firsthand as secretary of state. I saw what our medicines meant for people living with diseases like HIV/AIDS. Helping people to stay alive and become healthy is one of the ways America can show who we are, what we stand for, what our values are.

But at the same time, we need to protect hard-working Americans here at home from excessive costs. Because too often, these drugs cost a fortune. Now, sometimes, there is a good reason for that. Scientific breakthroughs are often the result of major investments, both by pharmaceutical companies and by your federal government. So it may make sense for a short period of time to have to charge a lot of money for a drug.

But when a drug has no competition, when there aren’t any other treatments that can do what it does, pharmaceutical companies can charge astronomical fees, far beyond anything that it would take to recoup their investment, and far beyond what they charge consumers anywhere else in the world outside of America.

It has gotten to the point where people are being asked to pay not just hundreds, but thousands of dollars for a single pill. And I can tell you that is not the way the market is supposed to work. That is bad actors making a fortune off of people’s misfortune.

Some of you may have read about an egregious example of this that was in the news yesterday. A drug that’s been around for decades—it wasn’t just invented with new research and new dollars backing that up, it’s been around for decades—that went from costing $13.50 a pill to $750 a pill literally overnight.

That’s price gouging, pure and simple. And pharmaceutical companies that acquire an existing, affordable drug that people rely on it, and then turn around and charge a fortune for it just bet on the fact that desperate people will find some way to pay for it.

At the same time this is happening, top pharmaceutical companies are receiving billions of dollars in tax relief every single year and earning billions of dollar in profits every year. And many of them spend more money on marketing and advertising than they do on research.

You’ve seen the millions of ads on TV, right? They often show people being really happy and running through fields of wildflowers, and if you take this drug your life will be so much better. Meanwhile, they’re telling you it has this bad effect and that bad effect and be careful about this and don’t take it with that. But the visual image is so attractive. And it’s something that has bothered me for a long time.

Now, I know that whenever anyone starts talking, as I have, about reforming prescription drugs and their prices, some people worry that my proposals will threaten innovation. But I have designed a plan that will do exactly the opposite. I want to both protect consumers and promote innovation, while putting an end to profiteering. We can achieve a win-win for families, businesses, and America.

There are leaders in the pharmaceutical and biotech industries who share my concerns about high prices. They know we need to make some changes. They just want to make sure it’s done right, and so do I.

So under my plan, drug companies who want to keep getting federal support will have to redirect more of their profits into meaningful investments in research and development. That’ll mean more breakthroughs, more good drugs, not fewer. The way I see it, if we, the American taxpayers, support your company, you should be focused on delivering results that benefit us, not just your shareholders and your executives.

And under my plan, I will make sure that when new drugs are introduced, doctors, businesses, and consumers can get clear answers about exactly how these new drugs will improve upon existing treatments.

I fought for this kind of transparency in the Senate, because here’s the truth. Too often, so-called “new” drugs are really old drugs that have just been tweaked a little bit. But then they’re marketed as breakthrough drugs, and they’re sold for high prices. Drug companies should have to explain why their new drugs are different and better than treatments on the market. Because I don’t want any of us paying for some fancy new pill that is no better than what’s already available.

I also want to tackle the direct-to-consumer advertising. I’m guessing that a lot of you might be surprised, even shocked, to learn your taxpayer dollars are actually helping pay for those ads. Other countries ban these ads because they are so often misleading. But at the very least, we shouldn’t be encouraging them with corporate write-offs where you can deduct the cost of marketing.

Under my plan, we will instead use that taxpayer money to fund innovation. I’d rather see more treatment, more cures, and way fewer ads, and I think a lot of us consumers feel the same way.

I would also like to make sure any ads the drug industry does run are approved by the FDA, so we will know they are accurate and understandable to those consumers who are watching or reading them.

Then there’s Medicare. You know, the more than 40 million Americans enrolled in Medicare represent a huge market for the drug companies. Therefore, I believe Medicare should be able to negotiate for lower prices for its members. This would be like what the VA now does. It’s a basic feature of a free market. But you know it’s actually against the law now for Medicare to negotiate for lower prices. And that makes no sense.

I have been fighting to change this law for years, and as president, I will get it done. I will require drug companies to provide higher rebates for prescription drugs to low-income Medicare patients, just like they have to do for Medicaid patients. That would save more than $100 billion in Medicare costs every year.

And you know how the Republicans are always talking about how Social Security is running out of money, and Medicare is running out of money? Well, they way exaggerate it. Don’t get all nervous about it. They love to make it sound like it’s going to happen tomorrow, with sort of ghostly music.

Well, we do have to make sure the Medicare trust fund is solvent. This would add to that. It would be a win-win.

Because what I see is if you get prescriptions or medicines that really help you, it doesn’t do you any good if you can’t afford to fill them.

So that’s why also under my plan I will cap out-of-pocket drug costs for working families. You won’t have to pay more than $250 a month for covered medications. And we know this can work, because several states have already do it. I want to do this nationally so that we can keep the costs down particularly for people who have a chronic illness.

Also under my plan, you will be able to import cheaper drugs from other countries legally. If the medicine you need costs less in Canada, you should be able to buy it from Canada, or any country that meets our safety standards.

You know, when I was privileged to represent New York, you know, look at the map, upstate New York borders Canada. Every week there would be buses of American seniors going over to Canada to buy drugs that were American manufactured, drugs that were invented by American companies, for a much cheaper price over the border. That makes no sense at all, folks. And when I’m your president, you will be able to do just that. Now, I don’t want you to have to drive to Canada, so you can order them online and get what you deserve to get.

I will also be sure we have more generics on the market. That will increase competition and give doctors and patients more choices, and save you money. Why don’t we have more generics on the market? Well, one reason is that the FDA’s Office of Generic Drugs has a huge backlog. Well, I’m going to give them the funding and the personnel to clear that backlog, and approve dozens of generic versions of expensive drugs. That’s easy to do. We can get it done. I will save you money, it will help you with your medical issues.

Now, we’ve also got to deal with other out-of-pocket costs like deductibles, co-pays, co-insurance. According to a report by the nonpartisan Kaiser Family Foundation that came out just today, four out of five workers face an annual deductible, and the average deductible has risen nearly 50 percent since 2009, and it is now on average over $1,000.

As a result, millions of Americans are having trouble paying their medical bills. Some of you may be in that category or know somebody who is.

So even though we are successful as a nation in reining in costs, I want you to also have the benefit of that.

Why is it not happening as much as it should? Because insurance companies have been keeping the savings for themselves, and shifting more costs onto families. My plan will address that. I think the insurance companies need to be put on notice that they have to help people afford the medical care they need, not make it increasingly expensive and difficult to access.

So I’m excited because I think this would really give so many families a real shot at being able to afford the health care that you need.

And with my plan we’re going to add on to the good work that was done by the Affordable Care Act. And it’s really important that we work together on this. We can’t let the Republicans tear the progress away. If we’re serious about raising people’s incomes, we have to bring down out-of-pocket costs. I’m sure in this election you will see all kinds of ads about the out-of-pocket costs for the Affordable Care Act, and the Republican solution will be get rid of the Affordable Care Act. That would be a mistake. What we’re going to do is build on and improve the Affordable Care Act.

I’m just going to keep doing what I’ve been doing for years, which is to fight for affordable, quality health care for Americans.

Thank you all very much.