Vice President Kamala Harris is rolling out her closing argument for president in a new TV advertisement that attacks former President Donald Trump on healthcare, entitlement programmes and taxes.

“What would a Trump second term look like? It’s all laid out in his Project 2025 agenda,” the narrator says. “He’d let insurance companies deny coverage for preexisting conditions, cut Social Security and Medicare and give tax cuts to billionaires.”

For months, Harris’s campaign has tied Trump to Project 2025, a 900-page handbook of policy proposals for the next Republican administration created by the conservative Heritage Foundation think tank.

There is considerable overlap between the people involved in the project and former Trump administration officials. But Project 2025 is not part of Trump’s 2024 agenda, and he has worked to distance himself from it.

With that in mind, the advertisement is a mixed bag of accuracy. It refers to Trump’s previous claims to repeal the Affordable Care Act (ACA), misleads viewers about “cuts” to entitlement programmes that are popular with older Americans and leaves out that Americans with average incomes would also receive some tax breaks under Trump.

What Trump’s and Project 2025’s plans say about preexisting conditions

To support its claim that Trump would allow insurance companies to deny people coverage for preexisting conditions, Harris’s campaign pointed to actions and comments by Trump and his running mate, Senator JD Vance, about repealing the ACA. The 2010 health law, signed by former President Barack Obama, requires insurance companies to cover people with pre-existing conditions.

In his 2016 presidential campaign, Trump promised to repeal the ACA, and as president, he supported congressional Republicans’ failed repeal-and-replace efforts.

During his 2024 campaign, Trump’s position has gone back and forth. At times, he has said he wants to replace the law with an “alternative”. But in March, he wrote on Truth Social that he is “not running to terminate” the law and instead wants to make it “better” and “less expensive”. During the September 10 presidential debate with Harris, Trump said he has “concepts of a plan” to replace the law, but he would “run it as good as it can be run” before instituting his plan.

More than 1,500 doctors released a letter on October 17 calling on Trump to reveal details about how he would alter the ACA, saying voters need the explanation to make an informed decision.

Vance tried to fill in some of those details in a September 15 interview on NBC News’ “Meet the Press”, saying their administration would deregulate insurance markets but would still “make sure that pre-existing coverage – conditions – are covered”. Days later, Vance floated the idea of grouping chronically ill people together in insurance pools based on their elevated risks. Risk pools refer to a group of people who share the burdens of health costs.

Putting chronically ill patients in higher-risk pools would reverse a key pillar of the healthcare law, which largely ended the practice by requiring insurers to put all individual market enrollees into the same risk pool. This is done to control premium costs by using the lower costs incurred by healthy participants to keep in check the higher costs incurred by less healthy ones, according to KFF Health News. Separating sicker people into their own pool could lead to higher costs for people with chronic health issues, experts say, potentially putting coverage out of financial reach.

Project 2025 does not call for eliminating the ACA or pre-existing coverage protections. It recommends codifying Trump-era rules to expand short-term, limited-coverage healthcare plans. Democrats call these plans “junk insurance”, arguing that they limit care, charge people with pre-existing conditions more and can lead to surprise medical bills.

Project 2025 would not cut Social Security, proposes some changes to Medicare

Harris’s advertisement is misleading about the Social Security plans of both Trump and Project 2025. Trump has said he would not pursue cuts for Social Security benefits, and none of the policy document’s 10 references to Social Security outlines cuts.

In his earlier campaigns and before he was a politician, Trump said about a half-dozen times that he was open to major overhauls of Social Security, including cuts and privatisation. More recently, in a March 2024 CNBC interview, Trump said of entitlement programmes such as Social Security: “There’s a lot you can do in terms of entitlements, in terms of cutting.” However, he quickly walked that statement back, and his comment stands at odds with essentially everything else Trump has said during the 2024 presidential campaign.

Trump’s campaign website says not “a single penny” should be cut from Social Security.

Project 2025 proposes changes to Medicare, including making Medicare Advantage, the private insurance offering in Medicare, the “default” enrolment option. Medicare Advantage plans have provider networks and can also require prior authorisation, meaning that the plan can approve or deny certain services. Original Medicare plans do not have prior authorisation requirements.

The manual also calls for repealing health policies enacted under President Joe Biden, such as the Inflation Reduction Act. The 2022 law enabled Medicare to negotiate with drugmakers for the first time and recently resulted in an agreement with drug companies to lower costs for 10 expensive prescriptions for Medicare enrollees. New prices will take effect in 2026.

Trump has said throughout the campaign that he will not cut Medicare.

Republican presidential nominee former President Donald Trump speaks at a campaign rally at the Resch Center in Green Bay, Wisconsin, on Wednesday, October 30, 2024. He says he will not cut Medicare [Alex Brandon/AP]

Project 2025 and Trump differ on taxes, but ‘tax cuts to billionaires’ are on the table

Generally speaking, the benefits from Trump’s tax plan would go to most income groups while flowing disproportionately towards wealthier Americans. Project 2025’s recommendations differ from Trump’s tax agenda, though its changes could also result in wealthier people paying lower taxes.

Under Trump’s 2017 Tax Cuts and Jobs Act, income up to $11,600 is currently taxed at 10 percent, income from $11,601 to $47,150 is taxed at 12 percent and income from $47,151 to $100,525 is taxed at 22 percent. People who earn more are taxed between 24 percent and 37 percent.

Project 2025 calls for creating just two income tax brackets: one at 15 percent and one at 30 percent, and eliminating most deductions, credits and exclusions. The programme says the 30 percent tax rate should start “at or near the Social Security wage base”, which is about $168,600 in 2024.

The Project 2025 plan does not specifically recommend eliminating the standard deduction, the dollar amount non-itemiser taxpayers may subtract from their income before income tax is applied.

If that were nixed along with most other tax credits, people making up to $190,000 would pay a higher effective tax rate on their whole income, while the wealthiest Americans would pay a lower tax rate.

This is not Trump’s plan. Trump says he would extend the 2017 tax law provisions, which are set to expire at the end of 2025. The law lowered taxes for all income groups, at least initially; wealthier taxpayers benefitted disproportionately. The Urban-Brookings Tax Policy Center found that the drop in tax rate ushered in by the law for the top one-fifth of the income spectrum exceeded that for each quintile grouping.

Trump would reduce the corporate tax rate from 21 percent to 15 percent for companies that make their products in the US. (The 2017 law had cut the corporate tax rate from 35 percent to 21 percent.) Trump has also floated several more targeted tax cuts, including ending taxation on Social Security benefits, tips and overtime pay.

The University of Pennsylvania’s Penn Wharton Budget Model projected the effects of both presidential candidates’ tax plans on a spectrum of income levels in 2026.

It found that Trump’s plan would increase post-tax income for every income group. However, the bottom two-fifths of the income spectrum would have gains smaller than 2 percent, the middle fifth would have a gain of 2.1 percent and the second-highest quintile would gain 2.8 percent. For cuts affecting the top one-fifth of earners, gains would range from 2.7 percent to 3.7 percent.

By contrast, the Penn Wharton model projected that Harris’s plan would increase after-tax income for the bottom one-fifth of earners by 18 percent, the second-lowest one-fifth by 4.8 percent, the middle one-fifth by 2.7 percent, and the second-highest fifth by 2.1 percent. The top 5 percent of earners would see after-tax incomes decline.