Trump vs. Harris on Health Care: Experts Explain Each Side

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Mark Masselli ( 00:04 ):
This presidential election offers American voters a clear choice on the issues of healthcare. Do they like
the policies of the Biden-Harris administration? Or do they want to return to the Trump era approach?
Andrea Ducas ( 00:15 ):
I think what you see with Vice President Harris is a candidate who is committed to protecting women's
freedom, to protecting the women's right to choose.
Margaret Flinter ( 00:26 ):
We are going to dive right into the healthcare policy debate with our accomplished guests. Andrea
Ducas is the Vice President of Health Policy at the Center for American Progress. Wayne Winegarden is
the Senior Fellow and the Director of the Center for Medical Economics and Innovation at Pacific
Research Institute.
Wayne Winegarden ( 00:43 ):
The problem with most global climate change policies that we're implementing now is that they're not
effective and that the cost in terms of reduced reliability of the grid, which is a growing problem that,
especially as we start moving towards some of these mandates that the Biden administration has put
into place... it is very disconcerting.
Margaret Flinter ( 01:03 ):
This is Conversations on Health Care.
Mark Masselli ( 01:14 ):
Andrea Ducas, welcome to Conversations on Health Care. Let's start with the biggest healthcare issue of
all right now, abortion. A Gallup poll found a record high 32% of voters said they'll "only vote for
candidates for major offices who share their position on abortion". And yet 85% of Americans believe
abortion should be legal in at least certain circumstances. What do you and others on the progressive
side want to see Kamala Harris do on the abortion issue if she's elected?
Andrea Ducas ( 01:46 ):
Yeah. Well, first thank you for having me. It's a pleasure to be with you today. But to answer your
question, I think what we're hoping for is that she will deliver on exactly what she says she's going to do,
which is work to restore access to abortion as the law of the land in this country. I think what you see
with Vice President Harris is a candidate who is committed to protecting women's freedom, to
protecting the women's right to choose, and advancing back toward a country where access to the full
spectrum of reproductive care is the norm and not the exception. So I guess that's how I would answer
that question.
Mark Masselli ( 02:29 ):
How about the filibuster? Is that something that you'd be supportive of her undertaking?
Andrea Ducas ( 02:35 ):

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I think there are a number of structural impediments that keep us from making progress toward
commonsense solutions that enjoy robust support, as you just described. Right? The vast majority of
people are supportive of having access to abortion, so yeah. I mean, any attempt to make it easier to
pass legislation that is reflective of the will of the people is something that we support. Yes.

Margaret Flinter ( 03:04 ):
Well, Andrea, former President Trump has disavowed the conservative blueprint that we call Project
2025. But you and your colleagues aren't letting him off the hook.

Andrea Ducas ( 03:14 ):
Yeah.

Margaret Flinter ( 03:14 ):
Explain to our listeners, how do you see Project 2025 and what it prescribes for the American healthcare
system?

Andrea Ducas ( 03:21 ):
Yeah. Well, former President Trump disavows a lot of things he then supports, so I would say we view
that sort of distancing as a distinction without a difference. It's very, very clear what the intent of Project
2025 was. You can just look to the report's authors to get a sense of how close they are to the former
president. And you can look to his own closeness with folks at the Heritage Foundation to get an
indication of exactly how intertwined that document is and that agenda is, with what you would expect
to see another Trump administration looking like. But, I think, again, what's laid out in that document is
an antithetical vision of America. It is a far-right authoritarian manifesto that would completely redo our
system of checks and balances in service of advancing the interest of a small minority of people who
want to take their will and insert it on the entire American public.
( 04:33 ):
I think it's not a surprise that former President Trump has tried to distance himself as much as possible
from what's laid out in Project 2025, because the proposals are wildly, wildly unpopular. The public has
seen these. They do not like what they see. So it's not surprising at all that you would want to see an
attempt to run from that. But, what's in there? We were just talking about abortion. I think it's pretty
consistent with where you see a future Trump administration going, I mean, look at what he talks about.
He's thrilled that he installed justices on the Supreme Court that overturned Roe v. Wade. Right? And
what do you see in Project 2025? Even more attempts to effectively outlaw abortion. Right? So it's very,
very consistent with where he seems to be wanting to go as a political candidate.

Mark Masselli ( 05:24 ):
Andrea, former President Trump has said he has, quote, "concepts of a plan" to replace the Affordable
Care Act, also known as Obamacare. His running mate, J.D. Vance, has added some more detail. He said
they wanted to group chronically ill patients in health insurance pools based on their elevated risk. What
would the results of such an action be?

Andrea Ducas ( 05:49 ):
It's a pretty disastrous health policy. Like much of what you see in the Trump-Vance agenda, it is a
hearkening to the past, going back to systems that don't work or that service just a small number of

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Americans. I think many voters forget what the world was like before the Affordable Care Act. It's sort of
amazing how much that bill reshaped the entire American healthcare system, right? Just fundamentally
change what people expect from the healthcare system. But all we need to do is look. It's not even that
old, right? It's 14 years old. But all we need to do is look pre-2010 to get a glimpse at how ineffective a
tool like a high-risk pool is.
( 06:35 ):
How does insurance work? Everybody buys into a system, risk gets spread out. Right? Premiums are
kept relatively low so that when people need to use coverage - they get really sick, they get cancer, they
get into an accident - there's enough money in the pool to pay for those kinds of services without
effectively breaking that bank.
( 06:55 ):
The plan to separate chronically ill people into high-risk pools, completely upends the notion of
insurance. Right? Those folks would be in their own pool with very, very, very high healthcare expenses.
States tried to do this before, again, before the ACA. They had a very, very, very, very difficult time doing
it. It's very expensive to finance those pools. They're very volatile. Because their expenses don't just
magically go away - you've just moved them into their own pool - you run out of the money that gets
allocated toward those risk pools very quickly. And you can't finance them necessarily on premiums
alone because, again, the expenses are so high it would effectively be unaffordable unless you really
heavily subsidize enrollment in such a risk pool.
( 07:46 ):
So what you would probably see, again, is what we saw in the past which is enrollment would be
capped. There'd need to be really, really... Like a fine-tooth comb that goes through it to decide whether
or not people even qualified because maybe they're too expensive. So I think it's just a throwback to the
wild, wild west that we had for folks who didn't have job-based coverage or public coverage pre-ACA.
It's a plan that doesn't work. It's a plan that we as a nation got signed into law. We got to a place where
we had a landmark health reform, the Affordable Care Act, to get us out of that past, so it would be
great to not go back to it.

Margaret Flinter ( 08:33 ):
Well, Andrea, Kamala Harris previously backed a single-payer health insurance system that we call,
generally, Medicare for All. But now her campaign says that she's focusing, this is a quote, "on
commonsense solutions for the sake of progress". I'm curious. Do you feel abandoned by this move and
what will her approach be to dealing with very expensive healthcare costs?

Andrea Ducas ( 08:57 ):
Yeah, it's a great question. I think, not at all. From my perspective, I think where the campaign is, is
where a lot of America is. Right? By and large, people are happy with the particular insurance product
they have. I mean, there certainly, certainly, certainly issues with affordability. Deductibles are very high.
Healthcare prices are really high, which relate to how much you're paying but are a somewhat separate
issue than what goes into out-of-pocket expenses. But I think where folks are is, they're frustrated by
how much they're paying.
( 09:33 ):
For the majority of people, we now have a record low on insurance rate. Whether you get coverage
through your job, whether you get it through the ACA marketplace, sometimes it can be really expensive

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to use if your deductible is high. And because the healthcare system has changed so much in the last 20
years, and you've now got these really dominant players, very large healthcare systems that charge very,
very, very high prices, you're also in a situation where often people don't know how much they're going
to be expected to pay when they go to receive care. They walk out the door with an exceedingly high
medical bill that they can't afford to pay and they feel cheated, which makes sense. I've got this
insurance plan I'm paying a lot of money for, and now I've got these astronomical medical bills. This isn't
fair. And they're right. So it's been really heartening and wonderful to see the current administration,
focus so much on trying to tackle medical debt, trying to make medical debt as a concept irrelevant. It's
been great to see action.
( 10:43 ):
I was just at an event today celebrating the attempts to wipe medical debt off of credit reports and to
really crack down on nonprofit hospitals who are required to offer financial assistance policies, but
don't. So I think progress in that direction is what people want.
( 11:03 ):
People also want to see the prices of prescription drugs come down. So I think building off of the
remarkable progress that we've been able to see through the Inflation Reduction Act, and in terms of
lowering out-of-pocket expenses on prescription drugs and Medicare is something that folks are very
supportive of. And Vice President Harris has planned to take those and extend those to the commercial
market and outside of Medicare I think is important and popular. So I think looking for ways to make
progress to actually address the pain and pressure points that people are feeling, which is what's coming
out of their pocketbook, makes a lot of sense.

Mark Masselli ( 11:45 ):
Andrea, let's talk a little bit about private equity, which is playing a bigger role in healthcare-

Andrea Ducas ( 11:50 ):
Yeah.

Mark Masselli ( 11:51 ):
... and the consequences are becoming clear, I think. We're reading about hospital bankruptcies.
Steward, and Prospect, and others. And patients really are left to their own devices to deal with the
mess. The vice president has little to say about the entire controversy. Cap as referred to the rise of
private equity is really a looming crisis. What would you like her stand to be in this area?

Andrea Ducas ( 12:19 ):
Yeah, what I would like to see... And I'm going to actually zoom out and say, over the past couple of
years, the FTC under the Biden-Harris administration has taken a pretty active role in trying to unpack
and address the role of both consolidation but also private equity in different markets, including
healthcare. So continuing to bring strong scrutiny into what's going on in private equity markets,
generally, but especially with respect to healthcare, is something that we would expect to continue and
hope to see continued. As you mentioned, we do describe this as a looming crisis. It certainly feels that
way. There are specialties that are really getting gobbled up by private equity practices... or private
equity investors.
( 13:12 ):

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And in part, this is a result of concentrated market power. The bigger your competitor gets... If you're a
sole practitioner, like you're a family doc running your own practice, it becomes harder and harder to
compete when the other folks in town are giant conglomerates. So you look to other sources of capital
and private equity becomes that source of capital. So they're coming in to fill the void in markets that
are really heavily concentrated. So another thing, again, that we would expect to see is a continued
strong regulatory stance and posture from the nation's competition watchdogs. So it's been great, again,
to see the joint efforts by the FTC, DOJ and HHS to really try to go after this. But again, to your point, I
think what I would like and expect to see is much more scrutiny on private equity investments in the
healthcare system.

Margaret Flinter ( 14:15 ):
Andrea, you referenced the issue of medical debt and what a hot topic that has come to be. I think
surprise billing is right up there with it.

Andrea Ducas ( 14:23 ):
Yes.

Margaret Flinter ( 14:23 ):
It certainly contributes to it. But I think, on a consumer level, that's definitely one that really sparks ire in
the American people. What specific proposals are on the table, do you think, that we could expect the
vice president to lean into in these areas if she wins?

Andrea Ducas ( 14:40 ):
Well, with respect to medical debt, she's talked about the desire to effectively wipe that out, to do
whatever she can to remove medical debt from... I'd like to see it removed from the lexicon, right? Like,
what a concept. Why is medical debt even something we accept in this country? So I think she's talked
about debt relief proposals. With respect to surprise billing, I think we see a... I would expect continued
attempts to really make that a reality and to push back against... I'm sure you and your audience know
that it's been challenging to watch the arbitration that's happened, primarily financed by private equity
practices, that have brought prices up in some cases. So I think, again, additional scrutiny to how that
process applies would be something that I would expect to see.

Mark Masselli ( 15:41 ):
Now we turn to our opposite view. Our guest is Wayne Winegarden, Senior Fellow and Director for the
Center of Medical Economics and Innovation at the Pacific Research Institute. Wayne, PRI has stated
that patients are not in control of their healthcare system and that we suffer from an opaque and
complex pricing structure that harms patients. What would you like to see the next president do?

Wayne Winegarden ( 16:07 ):
I would love to see the next president make some reforms that actually, like you were saying, starts to
put patients back in charge, starts taking care of some of the pricing system issues we have, specifically
with drugs. What we really need to do is get rid of a lot of the intermediaries that are, as opposed to
bringing these patients together with the providers, is actually making it more difficult, more costly. So
what we really need to do is reform the pricing system and reform who's in control of that doctor-
patient relationship.

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Margaret Flinter ( 16:41 ):
Well, former president Donald Trump recently said that his administration would pay for in vitro
fertilization treatments or would force insurance companies to cover them. But PRI has stated that this
would be the wrong thing to do. Really curious, why did you take that stand on this particular
procedure?

Wayne Winegarden ( 17:01 ):
Obviously, PRI, we're scholars and different scholars are going to have different opinions. From my
position, it's more of a mandate issue. I mean, to me, in vitro fertilization is something... It is very
important and the government shouldn't be involved in that at all. It's between the doctor and the
patient in terms of deciding that. So obviously, it should be legal. It should be something that people
have the option to do. And we need to keep the government out of it. And we need to allow patients,
people who are seeking treatment, to actually have access to the treatments that they need regardless
of what it is. That's... doctor and the patient. And I think that's really important that we don't have the
government dictating those terms.

Margaret Flinter ( 17:42 ):
Right. But this was about paying for it. And it sounded like the position was not whether it could be legal
or not but that insurance companies should pay for it. Did you take a position on that as well?

Wayne Winegarden ( 17:57 ):
Again, speaking for myself, not for PRI, the important issue is not to mandate it. So that we need some
insurance... Absolutely, we're going to cover it because people demand it and people want that. But part
of the problem that we're seeing with the ACA is that there are so many different mandates of different
types of coverage that it's harder and harder for people to get the insurance that's appropriate for
them, let alone the fact that our insurance isn't actually providing that key insurance benefit that we
need.
( 18:25 ):
If health insurance was doing what it was supposed to do, it wouldn't be covering first dollar payments
of when you go to a checkup. And that's not a financial risk. What we really need is health insurance to
be there for in vitro fertilization, right? When you actually have a costly medical procedure, that's an
actual risk. That's where insurance is supposed to come into play. That's what we're actually missing. But
the best way to get that type of coverage is to reduce the mandates and allow insurance companies to
be competing for enrollees by providing that best coverage. We don't have that, and that's the system
we really want to start moving toward. But the problem with mandates is that it makes it that much
harder for insurance companies to actually tailor plans to the way that people need it.

Mark Masselli ( 19:15 ):
Vice President Harris said she wants to preserve President Joe Biden's enhanced Obamacare subsidy.
Now, those subsidies are scheduled to end next year. Why do you believe this would be a bad move?

Wayne Winegarden ( 19:29 ):
Well, if we take a step back, we have to recognize that the subsidies are very costly from a budget
perspective. So we're spending a lot of money and we're not getting that much for the money we're
spending. So we're creating, again, a much higher-costing insurance product. And you also have to

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remember that most of the people that the ACA in terms of insured... It's through Medicaid, right?
About 17 million of the 19 million people who have gained coverage from the ACA is because of
expanded Medicaid so the subsidies... Again, you're talking about 20, $30,000 of spending for each one
of these plans, and you're not providing high quality health coverage.
( 20:12 ):
And so that's really the problem, is that we're spending a lot of money and not getting a lot out of it.
And so that becomes destructive. It's harmful to the economy. It's going to start actually impacting the
deficit, which could have negative consequences on interest rates, and then it snowballs from there.
What we really need to do is actually improve on that insurance product that we have, not through the
ACA subsidies, which is really just doubling down on policies that just haven't been working. So I think
that's the important reform we need to focus on.

Margaret Flinter ( 20:45 ):
We could have a lot of debates about all of these things, but I'm going to move on to another topic. And,
again, we're really paying attention to what the candidates are saying. And Kamala Harris says that she's
going to lower costs for American families by cracking down on price gouging by corporations that reap
excessive benefits. From your point of view, how are such actions harmful if that comes to pass?

Wayne Winegarden ( 21:09 ):
Well, we can talk about this in a lot of ways. Are we talking about the price gouging that she's alleging in
grocery stores or are we talking about price gouging... She's leveled that accusation across the board,
and that accusation is typically being leveled because there's been some sort of government failure, not
a failure on the private sector side. So let's take drugs for instance. We have problems that we need to
address in terms of how does a patent system work. We could absolutely improve that. But the bottom
line is that the cost of capital for developing a medicine, you're talking about 10 to 15 years, an
incredible amount of risk. There are very few medicines that begin, actually get to the place where it's
available to patients, let alone that it becomes a lot of sales. And you're spending $2.6 billion, with post-
marketing studies you're spending on average $2.9 billion.
( 22:02 ):
So this is an incredibly long, risky process, and it's incredibly important to recognize that it is the private
companies who are providing the lion's share of the money and the lion's share of the research. So
you're talking about $100 billion dollars per year the private sector puts into drug development. The
entire federal funds are going into just broad research overall is only about 20, 30, $40 billion. So you're
talking about a lot more money being spent by the private sector, and the private sector is better at
commercializing medicine.
( 22:36 ):
Why do I go through all of that? You have a very short period of time to recoup $2.9 billion. And that's
just the finances behind it. So what we actually need, again, going back to our insurance discussion, is
we need a better insurance arrangement to cover that. But that way we actually get the new
treatments. And we always focus on affordability, which is incredibly important, but we also have to
focus on... There are tens of millions of patients living with diseases, with inadequate treatments, with
no treatments, like Alzheimer's, muscular dystrophy. All of these conditions need new therapies, and
we're not going to get those new therapies without covering that cost of capital.
( 23:20 ):

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So bringing it back to your original question, price gouging. She's actually talking about imposing price
controls. That's her solution to the price gouging. And that puts at risk all of this development that's
brought us these fantastic drugs. We can now help people with obesity. We can help all sorts of cancers.
We need that process to continue. And accusations of price gouging and price controls really disrupts
that. And what the real issue is, how do we get better insurance? Not these accusations of price
gouging.

Mark Masselli ( 23:53 ):
Wayne, former president Trump has stated that he has no connection to the conservative initiative
called Project 2025 from the Heritage Foundation. And many now view it as a mistake to have these
ideas publicized. Yet project 2025 states that healthcare reform should be market-based. Do you feel
aligned with the many perspectives in the Project 2025 document?

Wayne Winegarden ( 24:18 ):
Well, I haven't read Project 2025. I can't tell you if I agree with it. I can tell you-

Mark Masselli ( 24:22 ):
It's only a concept.

Wayne Winegarden ( 24:25 ):
In concept, I do think we need to put patients in control. And we're talking about, that's one of the
things. If you think of the average employer plan, Kaiser Family Foundation, we're spending about
$25,000 per family, for employer plans. Some from the employee, most of that's contributed by the
employer. So can you imagine if we had $25,000, or call it $20,000, because $5,000 comes from the
employee. $20,000 to put into a health savings account that could go toward doctor visits, that can go
towards paying for catastrophic insurance. There's all sorts of amazing innovations that we could
incentivize where we would actually have the patient making decisions of, "Who do I want to see?
Who's my doctor?" And you have doctors and healthcare clinics who are actually trying to see, "How can
we serve the patient," not, "How can we serve the insurance company."
( 25:23 ):
And so I think to, again, collapse the system where patients and doctors are better connected, and
patients are controlling the... all sorts of innovations. We're going to get better healthcare. And if we
think about the healthcare issue as, we have a quality of care issue, we have an insurance issue, and we
have an issue of income. Right? That type of patient-centric care can help get those first two goals,
getting better quality of care and putting that patient in charge and getting better insurance out of it.
And then the government's role is then, how do we provide that safety net? How do we ensure that
people who don't have enough income to buy insurance can actually participate in that private market?
( 26:05 ):
But what we've done is we keep collapsing that into this Medicare for All discussion, which is really just
focusing on that one third of the problem. And it actually does a really bad job of trying to address that
one third of the problem. And so I think when you're talking about patient care, what you're trying to do
is expand it, trying to better identify what the issues are and come up with solutions to each one of
those problems.

Margaret Flinter ( 26:28 ):

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Well, I note, moving away from health insurance for a moment, that you've written about an issue that
is a concern, I think, to all of us here. That global climate change is a really critical problem. Former
President Trump has rolled back more than 125 rules and policies that were meant to protect the
environment and to lower planet warming emissions. So when we look at the upcoming elections, if a
voter is concerned about climate and maybe, particularly, its effect on health, who should they vote for?
Why should they vote for Trump or for the Democratic candidate? Then tell us why.

Wayne Winegarden ( 27:07 ):
Well, I would say this. I'm certainly not going to advocate for either one. To me, the issue with climate
change - and it's an incredibly important issue - but our problem is that the technology isn't there. And
so what we really need to do is incentivize innovation. And I think we need to do it technologically
neutral. We don't know yet which technology is going to actually sustainably address the problems that
we have. And so to the extent that we could provide really broad-based incentives for innovation, not
choosing, "Oh, we want to incentivize wind or solar," or whatever the technology is.
( 27:48 ):
So take tax breaks, where a company that develops a technology that has much lower emissions or zero
emissions, whatever the benchmarks are. That they're going to get profits, tax-free, for a dipping stick,
in order to incentivize research money to go into that area, when it raises the relative return for people
who are investing in these low-emission technologies, whatever it is. Whether it's natural gas, nuclear,
solar, batteries, hydrogen. I mean, I think we need to keep a very broad perspective, not pick winners or
losers, but to the extent that we can change the relative returns from people for investing in that type of
innovation, we could incentivize the development of the new technologies that we need.
( 28:36 ):
The problem with most global climate change policies that we're implementing now is that they're not
effective and that the cost in terms of reduced reliability of the grid, which is a growing problem,
especially as we start moving towards some of these mandates that the Biden administration has put
into place... It is very disconcerting that we're going to lose that baseload power and we're not going to
have a reliable replacement. And so, then all of a sudden power outages are going to be occurring. And
so that could be particularly troubling on a hot day or a cold day. We've seen that in Texas several years
ago. So we really need to focus on innovation, not these technologies that aren't going to get us there.

Mark Masselli ( 29:18 ):
Wayne, private equity is looming large in healthcare, and we've seen some real disastrous issues with
Prospect Medical and Steward Hospital... Steward Health. What's your view of the regulatory
requirement that should be placed on some of these institutions where real harm is being caused to
patients?

Wayne Winegarden ( 29:42 ):
Well, what you just said in terms of focusing on patients, I think that's the key we need to be
considering. And to the extent that the private equity is coming in and coming in with new ways of
delivering care, focusing on value-based care, getting away from fee-for-service models or
experimenting with new models, all of that could be very beneficial. But the ultimate arbiter in all of
these has got to be patient care. Because if you think about how so much of our economy has evolved
and changed compared to 50 years ago in terms of just communications. A telephone. I gave my kids

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one of the old-style rotary phones. They had no idea what to do with it. But cell phones are very
ubiquitous. They know exactly what to do with that.
( 30:30 ):
Healthcare is still the way we're delivering it from 50 years ago. It would be very familiar. You wouldn't
be confused when you walked into a doctor's office. And that's part of the problem. And the reason I
bring that up is because it's a careful balance. To the extent that the private equity money can
incentivize those types of changes and innovations, that's fantastic. Again, we have a very convoluted
system. We have a system where middlemen drive the market process, not the patients, not the
doctors. And so we need to make sure that all of these changes, in order to benefit the patients,
improving the patient experience, not something that's playing off of some of the inefficiencies and the
opacity that we have in the market that are just going to make things worse. So we've got to walk that
careful balance. But again, the ultimate arbiter is, how does this improve outcomes for patients?

Margaret Flinter ( 31:23 ):
Thank you to our guests, Wayne Winegarden, with Pacific Research Institute, and Andrea Ducas, with
the Center for American Progress. Most importantly, everybody, remember to vote on or before
November 5th.
( 31:35 ):
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for joining us today.

Speaker 5 ( 31:57 ):
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