Candidates and the Cost of Health Care

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Brian Lehrer: From WNYC in New York, and Marketplace from American Public Media, this is, America, Are We Ready? Hello, everyone. I'm Brian Lehrer from WNYC.

Kimberly Adams: I'm Kimberly Adams, senior Washington correspondent for Marketplace. For the next three weeks at this time, we're teaming up to help answer maybe the number one question on the minds of swing voters this year. Are we ready for what the outcome of this election will mean for the broader economy and our own personal finances?

Brian Lehrer: That's right, Kimberly. Before we dive into this question, though, we want to acknowledge a couple of things right at the top. One is that we know we're on tonight on many stations in Florida, and we're wishing everyone in the path of Hurricane Milton a safe night. I wish we could do more, but we at least want to acknowledge that that's happening in areas where you might be listening tonight and that we're thinking of you. I'm sure your local public radio stations have a lot of information and advice specific to wherever you are.

We also want to acknowledge that for many voters in this year's elections, passions are running high and the stakes are very high on a number of issues, including abortion rights, immigration, the state of our democracy, and more. Kind of depends which party you're in for many of these things. Some even call it a post-policy election, in which identity or what kind of country we are is really what it's all about. That's all true for lots of folks, of course, but policy always matters. Many polls have shown, as Kimberly was saying, that the cost of living is an especially important issue for the remaining undecided voters in the swing states.

In three successive weeks, we'll compare the candidates and their parties on healthcare costs, housing costs, and the cost of caring for children and elderly family members.

Kimberly Adams: Our topic tonight is healthcare costs. If you don't have insurance, and increasingly, even if you do, the price of going to the doctor or getting tests and treatments that you need can be really serious burdens. Sometimes those rising costs are pushing people to the financial brink or even into bankruptcies. Policymakers have been fighting over what to do about this issue for decades. Let's see where those main financial stress points are these days for many Americans when it comes to healthcare and what Vice President Harris, former President Trump, and of course, their parties in Congress say they're going to do about them if voters give them the chance.

Brian Lehrer: That's a great point about the financial stress, even for people who do have insurance. Here's a paragraph from a listener in Virginia who wrote to us for use on the air. That I think illustrates the point. The listener wrote, "Health insurance is sooo, so with three O's. "Health insurance is sooo expensive. We pay nearly $600 a month through my husband's job and still have a $40 copay plus a deductible. I have doctor bills for routine office visits that blow my mind." The person writes, I honestly don't understand why our coverage is so high if we still have so much to pay with each visit, meaning they don't know why the premiums are so high if they still have to pay a lot.

In addition, I am grateful, person writes, for the coverage, obviously, but this system is still clearly flawed. If a politician made a viable promise for changing this, it would definitely change my politics.

Kimberly Adams: Another listener wrote in, "Since my divorce last year, I have lost access to my ex-husband's retirement healthcare plan, which was very good. I am on Medicare, the dentist and eye care costs are so very high and would have been included in the plan he still favors. I'm a naturalized American from the UK where the medical program is wonderful. I have decided if ever I succumb to a really bad disease or ongoing healthcare issue as I age, I will pay for a flight back to my birth country for medical care there."

Brian Lehrer: Oh boy. So, America, are we ready to make healthcare more affordable? Kimberly, from your experience reporting and hosting for Marketplace, how prominent have healthcare issues been in the campaign so far?

Kimberly Adams: So far, it's been inconsistent because usually during a presidential campaign, and I've covered quite a few of them, you hear about healthcare all the time, but this cycle, we've heard a lot less about it until very recently. When it was Biden and Trump, you heard sort of vague promises about lowering the cost of healthcare and prioritizing maybe prescription drug costs, but we didn't get many specifics. Now, more recently, the Harris campaign has come out with some more detailed proposals, but nothing to the extent that we have seen in previous campaigns.

It makes sense, because if you look at how Americans are ranking healthcare in terms of priority, it's not as high up on the list as maybe in previous cycles. Some recent Gallup polling found that 37% of Americans say that healthcare is extremely important on their list of issues this presidential campaign, behind the broader economy, democracy, terrorism, the Supreme Court, immigration, education. If you break it down by party, there's also some difference there for Republicans. Only 31% of them say that healthcare is extremely important in this race. Democrats, 45%.

Brian Lehrer: Whoever wins control of Congress and the White House, what are some of the big healthcare issues they'll be facing once they get into office? Are they similar to the issues we heard from those listeners who wrote in?

Kimberly Adams: I think they are. I mean, somebody talked about prescription drugs. That's a big issue. I mean, the Biden administration has pushed through this Medicare drug price negotiation, and Harris has said that she wants to expand the ability of the federal government to negotiate for drug prices and lower the cost of insulin, for example. Another big issue that will face whoever ends up taking control of the White House and Congress is at the end of 2025, there are these subsidies that help people who are lower income or middle income afford to buy healthcare on the Obamacare exchanges.

Those subsidies are set to expire at the end of 2025, and the Congressional Budget Office has said that if those subsidies do expire, millions of people may drop their healthcare because they can't afford it anymore.

Brian Lehrer: Well, thanks for setting the scene for everyone in those ways, Kimberly. Now we have a great guest to help talk about affordable healthcare and the election. She'll be with us for the entire rest of the hour, including to take your calls, it's Julie Rovner. Julie is chief Washington correspondent for KFF Health News, and she hosts a health policy podcast called, What the Health?

Kimberly Adams: You might recognize her name because she was NPR's health policy correspondent for a long, long time. She also has a book, healthcare Politics and Policy A to Z. Julie Rovner, thank you so much for joining us for, America, Are We Ready?

Julie Rovner: It is a pleasure to be here.

Kimberly Adams: Julie Rovner, you've been covering this for such a long time. I'm curious what you see differently in this campaign when it comes to healthcare and also what's ahead for whoever takes office.

Julie Rovner: It's funny, this year I think reproductive health has really taken the forefront in terms of healthcare issues. In many previous elections it was super important, but people didn't realize it. We were fighting about the Affordable Care Act or before the Affordable Care Act, we were fighting about Medicare, even though really the Supreme Court and what was going to happen on reproductive health was on the line in the election. Now, of course, that's already happened and people are reacting to it.

We're having kind of a reversal, if you will. As you've mentioned, it's going to be a very important election, or who gets elected be very important for what happens in healthcare, particularly to the Affordable Care Act, particularly with those extra subsidies expiring at the end of 2025. Most of what we're fighting about right now, at least on the campaign trail, is reproductive health.

Brian Lehrer: According to the Economic Policy Institute, Julie, as I'm sure you know, as many as 29.8 million people, basically 30 million people, would lose healthcare if the ACA were repealed. What kind of fallout is being predicted if some of those provisions actually expire?

Julie Rovner: That's right. It would be as Kimberly said, this is what helping not just low-income people, but a lot of middle-income people afford those premiums that, as people, some of the listeners were saying are very high. It basically bought those premiums down so that they can afford it. I think it's 80% of people have access to a plan that costs $10 a month or less because of those subsidies. If they were to expire, premiums would go back up and people would have difficulty affording it. There's also the question, I'm sure we'll get into this, of what will happen to the Medicaid program that was expanded in almost every state under the Affordable Care Act.

Republicans have talked about making that possibly go away or taking away the extra federal money that's going to those states that could also see a large number of people lose insurance. I think right now the biggest health concern among people is how much they're paying if they have insurance. That's because we're at an unusual place right now where most people have insurance. We're up around 90% of Americans have health insurance. Some of them can't afford to use it. Many of them can't afford to use it, but most people at least have some basic coverage.

Kimberly Adams: I want to hear from you, Julie, quickly. Have you heard anything that jumps out to you on the campaign trail about any of these issues?

Julie Rovner: Well, we, of course, as you mentioned, we saw Vice President Harris just this week talk about expanding Medicare cover more in terms of long-term care, something that lawmakers have been talking about and trying to do for the 40 years I've been covering this and have so far not succeeded in doing it, adding things like dental coverage and eye coverage to Medicare, which also hasn't happened. Again, these are things that would be very popular and also very expensive.

Brian Lehrer: We're coming on a break. It's America, are we ready to control healthcare costs? The first of our Wednesday night election specials. We continue in a minute.

Kimberly Adams: Welcome back. It's America, Are We Ready to control healthcare costs? The first of our Wednesday night election specials. Next week, America, Are We Ready to control housing costs? I'm Kimberly Adams, senior Washington correspondent for the public radio program Marketplace.

Brian Lehrer: I'm Brian Lehrer from WNYC in New York. We're inviting your calls and texts on the question. You can text us, too. How are healthcare costs impacting your personal finances? What would you like from government policy on keeping those costs manageable? 844745 TALK 844-745-8255 and let's take a phone call right now. Here's Dusty in Allen, Texas. Dusty you're on America. Are We Ready? Thank you so much for calling in.

Dusty: I appreciate your time. Thanks for taking my call.

Brian Lehrer: Do you have a story about your health costs?

Dusty: Yes, absolutely. I've got a great story. I'm a type one diabetic. My son's a type one diabetic. A few years ago, I about broke down because I went to a Walgreens for a prescription for insulin that we have to have for both of us, and it was over $2,000 for one of my prescriptions, not even his. I was literally spending my entire paycheck and then some as an educator educating young people public school K through 12 for over 23 years now. What I've noticed is my premium right now is $1,700 a month to cover my family members.

Brian Lehrer: Wow, that's just your premium. That's before you pay co-pays and anything else.

Dusty: That is my premium, yes. I hear people complaining about 600, I'm like, "I wish I had 600." I went to Ikea last year and worked a year there because I needed healthcare and my premium was $400 and something a month and the coverage was better. The reason why I'm calling it, I'm so passionate as an educator is I'm not going to stop doing what I love at the sacrifice of my finances, but at the same time, I have to provide for my family. My big question for your listeners is, how does that affect the pipeline for teachers? Because we have 50% or more attrition rate for teachers within five years here in Texas, at least. Principles, it's 18% yearly. I ask you this, if we can't afford to stay in that profession, it not only affects me, but it affects your children because they're not getting the teaching that they need because they don't have the teacher pipeline to feed it properly. I bet you $100 to 1,000 that the young teachers coming in don't even know once they start their families, that they're going to end up paying these $1,700 premiums. [crosstalk] strict, contributing $400 a month.

Brian Lehrer: I hear you. Dusty, thank you very much. I'm sure this is very different from school district to school district. Julie Rovner, I imagine that we among the three of us, Kimberly and you, and me, don't have the data to say how healthcare costs and what people have to contribute to their premiums are affecting the availability of teachers or the willingness of people to work in the teaching profession. That's some story that Dusty told. Wow.

Kimberly Adams: Right. Also, Julie, I'm wondering if you can talk specifically about insulin, because the Biden administration has pushed to lower the cost of insulin for at least people on Medicare, and this has come up on the campaign trail.

Julie Rovner: That's right, it has. Of course, President Trump sort of started this when he was in office. He created a demonstration program for $35 a month insulin, but it was the Inflation Reduction Act that was passed under President Biden that set it in place for the Medicare population. They wanted to extend it to everyone, and they could not get that last 51st vote in the Senate with Joe Manchin sort of at the end to the Democrat now retiring from West Virginia who just couldn't bring himself to go that far.

That's something that the Biden administration has been talking about a lot, that Vice President Harris has been talking a lot that should the Democrats control the Senate and have 51 Democrats who are willing to vote for that, something they very much want to do. Just today, KFF came out with its 2024 survey of employer-provided health insurance, and the average employer-provided family premium is now $25,000, of which the family is expected to pay $6,000. That's the average. This is across the country, big companies, small companies. It really is as we talked about before, people have insurance, but then they can't afford to use it.

Brian Lehrer: Are there policies, Julie, that you're covering from not just Trump or Harris, but leading Democrats or Republicans in Congress to do something about those premiums for people who do actually have healthcare insurance through work but still are paying so much?

Julie Rovner: A lot of it is kind of whack-a-mole right now. It's not so much looking at premiums. Of course, in the last few years, Congress did pass the No Surprises Act, which was to stop these unexpected bills from people who ended up out of network in an emergency and then suddenly got these huge bills from out-of-network providers. Congress put a stop to that, although they're still working on implementing it. Right now we have these private equity groups going in and buying up hospitals and buying up doctor practices.

We're having insurance companies fighting with hospitals and doctors and patients are still caught in the middle. I think we're getting to the point where really even experts aren't exactly sure what to do about the spiraling cost of healthcare. Clearly in the United States, paying way more than our fellow industrialized countries, and no one is quite sure how to make that stop.

Brian Lehrer: Let's take another call. Here's Jerester in Greensboro, North Carolina. I think, coincidentally, another teacher. Is that right? Jeresta, you're on, America, Are We Ready? Hi, there.

Jerester: Yes. Yes, sir. Hello. I'm glad to be on speaking as an educator here in North Carolina. Yes, I was listening to Dusty talk about being an educator. Unfortunately for me, our healthcare here is pretty good. I don't pay as much as he does, but I pay about $8,000 a year. Still, as a teacher, our coverage is actually included with our paycheck, but if you want to add your family on, of course, there's an additional cost. I think one of what my two cent or what I would do to help lower the healthcare cost for Americans is at least like teachers and firefighters and police officers, I don't know, nurses. I think they call them frontline workers. I'm not sure, but how we have healthcare included with our check, but we want to add a family member. Perhaps they could also join us if we choose to do so with the same fraction of a cost that as the employee that I pay and not having to pay an additional--

For example, I pay $800 a month for my family to join. It would be nice just to pay a fraction of the cost, or no cost at all, because I know there are some countries that offer that, and I know America can make some kind of laws to help Americans out.

Brian Lehrer: Jerestra, thank you very much. Yes, I guess that's a particularly surprising thing for a lot of people who maybe when they have dependents, maybe they're just recently married or just recently have a child, and they had health insurance through work. Then maybe it comes as a shock that, "Oh, I have to pay an additional x per month to include my household family members. I don't know if there are policies in the hopper to deal specifically with that. Let's go to another call. Oh, go ahead Julie. Did you want to say something?

Julie Rovner: This is something that the Biden administration did change, something called the family glitch in the Affordable Care Act, which said that if you were an individual and you got employer insurance subsidized but not your family, that your family was then not eligible for subsidies, and they changed that. Now if the employee gets a subsidy from their employer, but the family doesn't, the family can go to the ACA Marketplace and they are eligible for a subsidy. That was actually a big change to help exactly that problem.

Brian Lehrer: Yes. Let's go next to Patrick in Lakewood, Ohio. Patrick, you're on America, Are We Ready? Hi there.

Patrick: Hi. I think that controlling healthcare means controlling healthcare rather than throwing money at it. I'm wondering what your guests think about which of the two candidates is going to be more likely to regulate big pharma, insurance companies, and large medical organizations that run hospitals that are making obscene amounts of profits while Americans go without healthcare.

Brian Lehrer: It's really a great question. Kimberly, I wonder if you cover this on Marketplace very much. We talk about the Affordable Care Act. The question on this show is how do we control healthcare costs? Really what we so often wind up talking about is how do we wind up subsidizing people so they can afford the healthcare costs that are out there, and it doesn't necessarily put a cap on the cost, at least not in many areas.

Kimberly Adams: Right. One area that the Biden administration has really kind of dug in on, and it's anticipated that a potential Harris administration would do the same, is going after consolidation in the healthcare industry and sort of these different parts of the healthcare industry that have done or that are engaging in what the Biden administration has called price gouging, whether it's the pharmacy benefit managers, whether it's pharmaceutical companies. You see the Federal Trade Commission led by Lena Khan, really going after a lot of these companies, saying that they want their books, they want to know how they're setting prices and how they are working together.

Is there a legal collusion? Now, the Trump administration also went after big companies jacking up prices a bit while he was in office, but it's a little bit less clear whether or not he'd pursue the same sort of aggressive approach here. Julie, I'd be really curious to hear your thoughts on this.

Julie Rovner: Yes, there's a couple of big differences. One of them, of course, has to do with the Supreme Court, and they overturned this very esoteric thing called the Chevron doctrine.

Kimberly Adams: The Chevron doctrine.

Julie Rovner: That's going to take away an awful lot of power of either administration, no matter who is elected, to do this kind of regulating. The other thing is that when the government does try to regulate very powerful health interests who make a lot of money, they go to court. We now have all of these more conservative judges on the courts who tend to rule in favor of the big businesses, and then we come to the Supreme Court. Even if President Trump was reelected and wanted to go after some of these entities, it may well be that some of the judges that he appointed and that his Senate approved might stop him.

Brian Lehrer: Let's take one more call in this first chat. This is Leslie, a self-employed person in St. Louis. Leslie, you're on America, Are We Ready? Thank you for calling in.

Leslie: Thank you. I was just calling in because as a self-employed person, I have to cover my family, and our health insurance cost is $2,400 a month, which is $29,000 a year. It's not great coverage. It's actually very-- It's bad coverage. We expect our out-of-pocket this year, by December will be $18,000 beyond the health insurance cost.

Brian Lehrer: Wow. Can I ask, Leslie, do you get that insurance on the Obamacare Marketplace or somewhere else?

Leslie: We do not. I just bought an independent plan. I did look into the Marketplace, and the cost was similar. We did not qualify for any subsidies. We're middle class, probably a little higher middle class, and so we don't qualify for any subsidies through the Marketplace.

Brian Lehrer: What, if anything, do you have in mind that you would like the federal government to do to help you with that astronomical health insurance bill?

Leslie: I thought about it, and I don't necessarily think subsidizing the cost of the health insurance is a long-term solution. Maybe what your previous caller said, like taking care of the actual cost of medical procedures and prescriptions and things like that, because I will say this, knowing that I have terrible insurance, if we do have to have something done, I shop around. The difference from one hospital in St. Louis to another on cost, if you ask and drill down, can be very significant. Well, it's not transparent, and there's no consistency in pricing on medical costs.

Brian Lehrer: That's very revealing. Leslie, thank you very much. Again, Julie, on healthcare cost transparency, and also, I guess we learned from that call that the Obamacare Marketplace doesn't necessarily give a better price than just the open Marketplace to some people who have to buy their own insurance.

Julie Rovner: That's right. I mean, and it really is, it's the sort of upper-middle-class people who get hit the hardest because they make too much to be eligible for subsidies, but not enough to be independently wealthy and not worry about how much their insurance costs. That has been a problem from the beginning of the Affordable Care Act. When they put in those extra subsidies, they went a little bit higher up the income scale, but there are still a lot of people who are still struggling. The caller sounds like a lot of experts I talked to.

It's just there is no transparency. It's almost impossible to find out how much things cost, certainly in advance. It's almost impossible to find out how much most things cost. If you don't know how much they cost, it's very hard to shop around.

Kimberly Adams: I should say that there have been efforts by both the Trump and Biden administration to improve hospital cost transparency, surgical cost transparency that have been just without teeth and ineffective. Right, Julie?

Julie Rovner: Yes. Well, I won't say they've been without teeth. They're working on it. I mean, the problem is it's just so complicated that even if you post the prices, which is what they're supposed to do, there's so many different prices and different codes, it's still impossible to know how much a particular thing is going to cost you. You might be able to cost for a simple MRI, but I know people, I have lots of friends who are pregnant and ready to give birth, and they want to find out what the difference is going to be in cost for where they're going to give birth, and they literally cannot find out. There are just too many variables there.

Brian Lehrer: Let's sneak in one more call before a second break, and then we have some, I think, very interesting clips of Trump and Harris to compare them in a particular way. That'll be when we come back from a break. Let's sneak in one more call before the break. Monica in Maryland, a social worker, I believe. Monica, you're on, America, Are we ready? Hello.

Monica: Hi. Thank you so much for taking my call. Yes, no, I just wanted to say that I work with older adults, and what I'm observing a lot over the years is that people are not prepared for how much it's going to cost to take care of their older adult relatives. A lot of times when people have dementia, they are [inaudible 00:27:02] where they may not be able to return home. Their family is looking at facility placement, whether that's in a nursing home or an assisted living community. They are always shocked at how much it's going to cost.

They're always surprised at how they're going to have to go through a financial screening to talk about how their loved one is going to be able to afford this until they maybe have to apply for long-term care Medicaid. I'm also seeing a lot of people have to get guardianship because their family has no access to their finances. They could have maybe done a power of attorney years before, but they didn't because it was an uncomfortable conversation or they thought it was being negative and they didn't want to be talking about such heavy things. My thing is like, yes, but you're protecting your legacy. When people come into the hospital--

Brian Lehrer: That's right. A lot of people don't even know about power of attorney. Let's address this when we come back from the break, whether there's anything for people facing long-term care as we continue on, America, Are We Ready? Stay with us. It's America, Are We Ready to control healthcare costs? The first of our Wednesday night election specials. Next week, America, Are We Ready to control costs? I'm Brian Lehrer from WNYC.

Kimberly Adams: I'm Kimberly Adams, senior Washington correspondent for the public radio program Marketplace. We're also joined by KFF's Julie Rovner. Julie, I want to follow up with you with something our caller mentioned in the last segment, about the rising cost of caring for older relatives and how unprepared so many people are for an aging relative. Two things that jumped out to me there. Number one, the federal government is absorbing a lot of those rising costs. Also, the Harris campaign recently released something on this. Can you talk about those two things?

Julie Rovner: That's right. And it's not just the federal government. It's the federal government and the state government through the Medicaid program, they share the cost. I started covering healthcare in 1986, and that year I did my first big story about how the US had no long-term care policy, and it's almost 40 years later and the US still has no long-term care policy. The only program that covers basically the cost of custodial care is Medicaid. To get on Medicaid, you have to spend down all of your money and basically bankrupt yourself in order to have that paid for.

That's how much of the nation's nursing home bill is now paid. Members of Congress, both parties' presidents have talked about this since the 1980s. They've tried. There was actually a long-term care program that was passed as part of the Affordable Care Act in 2010, but they literally couldn't figure out how to make it work, and it was shelved. Now Vice President Harris has come out again and said, we really need to do this. It will be very popular, but it's also very expensive because most people are eventually, if you're lucky enough to live long enough, you're going to need some sort of long-term custodial care.

Brian Lehrer: I want to play a couple of clips of Kamala Harris and Donald Trump. I think we'll hear that for Trump, the question is whether he has evolved enough on this issue. For Harris, it's why has she changed so much? Here is Trump from a televised debate in 2020 during that election cycle. You'll hear that he wants to repeal Obamacare but has no plan to replace it.

Trump: I'd like to terminate Obamacare, come up with a brand new, beautiful healthcare. The Democrats will do it because there'll be tremendous pressure on them and we might even have the House by that time. I think we are going to win the House. Okay, you'll see. I think we're going to win the House, but come up with a better healthcare, always protecting people with pre-existing conditions.

Brian Lehrer: That was Trump four years ago in one of the debates. Many of you know about the follow up to that in this year's debate with Harris just recently. This begins with a question from moderator, ABC's Lindsey Davis.

Lindsey Davis: Just a yes or no. You still do not have a plan.

Trump: I have concepts of a plan. I'm not president right now, but if we come up with something, I would only change it if we come up with something that's better and less expensive and there are concepts and options. We have to do that.

Brian Lehrer: Well, he had four years since the first clip, but still no plan to replace Obamacare. As for Harris, here's an exchange that she had with CNN's Jake Tapper when she was running for president back in 2019.

Jake Tapper: You support the Medicare for all bill, I think, initially co-sponsored by Senator Bernie Sanders. You're also a [unintelligible 00:31:41] I believe it will totally eliminate private insurance, so for people out there who like their insurance, they don't get to keep it.

Harris: Well, listen, the idea is that everyone gets access to medical care and you don't have to go through the process of going through an insurance company, having them give you approval, going through the paperwork, all of the delay that may require. Who of us has not had that situation where you got to wait for approval and the doctor says, well, I don't know if your insurance company is going to cover this. Let's eliminate all of that. Let's move on.

Brian Lehrer: Harris, as a Democratic primary candidate in 2019, and to set up a question for you, Julie, I also want to read a text that we just got a couple of minutes ago from a listener who identifies himself as a physician in Minnesota. He writes, let's stop acting like this cost problem is a mystery. The rest of the modern, prosperous world has given us great examples of how to control healthcare costs. Why is healthcare in the US thousands of dollars more per year compared to other modern countries, but our outcomes are inferior? They have systems. We have a situation dominated by revenue-hungry businesses. It goes back to what Harris, I guess, has walked away from a Medicare for-all plan like some other Western industrialized countries have. Why does Harris say that she moved away from the Bernie Sanders model?

Julie Rovner: Because there weren't going to be the votes for it. There's been a longstanding sort of, I won't even say a plurality, a large minority of Democrats who are very firmly for Medicare for all. As the listener points out correctly, there are a lot of people who make a lot of money off of the US healthcare system. It would be extremely difficult to say, sorry, you guys aren't going to be able to make that much money anymore. That's literally why we've not been able to do very much about this. As Kimberly said earlier, we've seen a lot of consolidation, other businesses getting into healthcare, more people in more basically different lines of work making money off of the healthcare system.

The more people who pile in and are getting rich off of it, the harder it's going to be to disentangle all of that.

Brian Lehrer: Yes. Do the Republicans in Congress, I saw something about Tom Cotton recently, have a plan to repeal, I mean, to replace Obamacare? If they repeal it, they obviously don't like the Bernie Sanders model, but they say they're against big pharma, too. Do members of Congress have something to replace Obamacare with if Donald Trump himself doesn't?

Julie Rovner: In health policy circles, this has been kind of a running joke. That way predates Donald Trump getting on the scene about Republicans who wanted to repeal the Affordable Care Act and replace it, and the answer was always, with what? They always said, we're about to come up with something and they literally never have. In the now 14 years since the Affordable Care Act passed, they have not come up with anything to replace it because they can't figure out what to do either. It really is very difficult. They can say, well, we hate this, but they can't say what they would like better that they think would work.

Brian Lehrer: Let's go back to our phones. Kylie in Northern Virginia, you're on America, Are We Ready? Hi, Kylie.

Kylie: Hi, Ryan. This is Brian in the morning, Brian in the evening. This is wonderful--

Brian Lehrer: That's for those of you who listen to my New York morning show. A lot of people listening around the country don't know about that show, but, Kylie, thanks. Go ahead.

Kylie: Listen, I've given up on the premiums. I've just come to understand we pay $650 a month through an employer-sponsored plan for three people. I know people are paying four digits, so I get it. The premiums are going to stay high. I don't even understand deductibles. I have a PhD, and my brain does not understand what a deductible is. Having given up on the premiums and now understanding I have a deductible, and then I have to pay out of pocket for my copay. If I could have the government wave a wand, I would at least say, can you widen what's covered?

I have a seven-year-old. We go to the dentist. I'm told that a fluoride treatment is not covered. Why a fluoride treatment is not covered for a growing kid, I have no idea. He needs speech therapy. Not covered. My husband goes to the emergency room. It turns out he has bronchitis. The doctor gives him a nebulizer. The nebulizer, not covered. It's like I'm paying all this money, but then the things that my doctor is saying that I actually need or that my family needs is not covered, and so if there could be some regulation, at least around that, then maybe I wouldn't feel so silly paying so much money.

It's the paying the money and then still not being able to get the services that you're paying the money for that makes it like, why am I even paying for health insurance?

Kimberly Adams: Julie, I think that she is vocalizing the frustration that so many people across the country feel. A lot of the attention is focused on the presidential race, but who controls Congress also really matters. Can you lay out for us a couple of scenarios of what might actually happen in terms of meaningfully changing healthcare policy in this country depending on the balance between the White House and Congress?

Julie Rovner: That's right. It really does matter. There are some bipartisan healthcare issues that members of Congress are working on, but a lot of them, things like this, there is, and I will say the collar, it's better than it used to be because the Affordable Care Act did create essential benefits that did not exist before. There are more things covered now than there would have been if this was 15 years ago. I also have felt the pain of, yes, you need this, but it's not covered, or you need this, but it's only covered in part.

It is a constant trade-off. The more you covered, the higher the premiums are going to be. The higher your deductible, the lower your premium is going to be because you're going to pay more of your own bills. It's just a matter of passing around this hot potato and seeing who is going to pay it, but it's true. Even if Vice President Harris is elected, if there's a Republican Senate and or a Republican House, it's going to be very difficult to get very many things through.

Likewise, if former President Trump is reelected, but there's still a Democratic Senate or a Democratic House, it's going to be more difficult for him to get things through, although there are probably more things that a Donald Trump could do administratively than a president Harris could do. That's simply because most of the things that could be done by an administration have already been done by the Biden administration, so there wouldn't be that many things for her to change.

Brian Lehrer: You know, Julie, the caller, Kylie in Northern Virginia, says, I have a PhD, and I don't even understand what a deductible is. When you think about it, I guess we tend to accept the idea of a deductible by now. I don't know, maybe we're resigned to it, but is a deductible anything more than the insurance company kind of tricking us into not fully covering us and creating a category out of thin air? Right? We're covered for x, y, and z. Oh, but the first $500 of x, y, and z has to come out of your pocket. That's the deductible. Did they just make that up as a money grab?

Julie Rovner: Well, that's how insurance works. I mean, it's a little bit easier to see in car insurance because they'll tell you if you want a $100 deductible, your premiums can be higher than if you have a $500 deductible because there's only really those couple of things that are in play. In health insurance, there's a lot more, as we keep hearing. Things that are covered. Things that are covered in part. Things that are covered only if you go to somebody in their network. Things that are covered only if you try three other things first. There's lots of different ways to do it, but it's this continuing struggle about who's going to be the ultimate payer.

Brian Lehrer: Yes, and I guess you're right. Like in car insurance, at least somewhat like in car insurance, you can pay a lower premium for a plan if you accept a higher deductible, paying the first x dollars out of pocket more than on some other plan. Michael in Cleveland, you're on America, Are We Ready? Hi, Michael.

Michael: Hi. The basic cost of healthcare is so high in America because we are not as healthy as we could be.

Brian Lehrer: Can I jump in for a second, because it looks like you have a very interesting credential relevant to this topic. Do you want to say what it is? I think you told our screener.

Michael: Sure. I'm the chief wellness officer emeritus at the Cleveland clinic, and so my job was to help us control our own costs in addition to helping people live healthier longer, but in our own cost. If you have a normal blood pressure, normal LDL cholesterol, et cetera, what we call six normals plus two. By doing that, we had a voluntary program for our employees to do that. It is allowed in the ACA, and you can reimburse or incentivize employees to get there. When we started this, 6% of our employees had what we call six normals plus two. Now, a little over 44% have it, 74% voluntarily participate.

The clinic itself does not spend about $190 million a year, based on trendline or based on our competitive analysis with other institutions like us. Our employees get another $50 million, roughly reduced premiums because of that. Not only that, they are predicted, based on the way we look at the data, to live about 15% longer without disability. It is a win for the country. If we did that for the country, we would save a little over a trillion dollars a year in healthcare costs, and it would be manageable for everyone if they did this.

It is, yes, people with disability get a special, different, if you will, goals to hit, but it is, you hit those goals, and you can radically change healthcare costs in America back to what they are in other countries.

Kimberly Adams: Julie, I wonder, I mean, we've got a solution here. How feasible is this solution? What would it take for the federal government to get on board with something like this?

Julie Rovner: The problem with a lot of things like this is that they work where they work and they're great. We haven't found things that are scalable. We went through this in the early 2000s. They got together all these places that had done such a good job at improving the health of their populations and keeping their medical costs low, and it was wonderful. Nobody could figure out how to make it work anywhere else. Where it works, it's awesome. Figuring out how to make it work for everyone, that hasn't happened yet.

Brian Lehrer: One more call. Let's make it Ritch in Hackensack, Minnesota. Ritch, we've got about 30 seconds for you. Hi there.

Ritch: Hi. I'm just wondering why they don't when they're trying to improve healthcare or get people on board, why they don't ever mention that if somebody can't afford healthcare, they're going to go bankrupt because their medical bills are so high, there's no insurance company to fight part of it for them. Once people go bankrupt, now we're paying for everything for them instead of just paying part of their healthcare bill. Nobody--

Brian Lehrer: I kind of have to jump in for time, but Julie, briefly, it goes back to the caller who was talking about long-term care for mostly elderly people who need it, and that it's-- People wind up going bankrupt, spending down all whatever money they have because the ultimate fail-safe backup is Medicaid, right?

Julie Rovner: That's right. It's the same thing if you get hit by a car, you're going to be taken to the emergency room and you're going to be given emergency treatment because that's required, but if you get cancer and you don't have insurance, that's not an immediate life-threatening emergency, even though it's going to kill you and you're not going to get care. There are a lot of things that are wrong with our healthcare system, but also, no one ever said it was efficient.

Brian Lehrer: Well, we could talk about this all night, obviously. Unfortunately, in America, we've been talking about it for decades, and we have patchwork solutions piece by piece by piece and still look where we are with so many people. You can just hear it in the voices of our callers overwhelmed by healthcare costs. That's the first edition of our Wednesday night election series, America, Are We Ready? Our topic tonight has been America, are we ready to do something about healthcare costs? Next week, America, Are We Ready to do something about housing costs?

Kimberly Adams: America, Are We Ready? Was produced by Zach Gottehrer-Cohen, Megan Ryan, and Alyssa [unintelligible 00:45:20]. Matt Marando is at the audio controls.

Brian Lehrer: Right. I want to thank Julie Rovner from KFF Health News. Julie, such a great job. Even though you don't work for NPR anymore, you're still an ace on the healthcare beat. Thank you so much.

Julie Rovner: Always a pleasure.

Brian Lehrer: I'm Brian Lehrer from WNYC. If you want to follow my other work, you can listen to my daily politics podcast. It's called Brian Lehrer, a daily politics podcast.

Kimberly Adams: I'm Kimberly Adams, senior Washington correspondent for Marketplace. If you'd like to follow our reporting on the economy and this election, you can find Marketplace in any of your podcast feeds along with the show I co-host with Kai Ryssdal, Make Me Smart. Thanks, everyone, for tuning in tonight.

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