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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

Hard Questions on Health Care

Tonight, President Barack Obama and Governor Mitt Romney will square off in their second debate, the final one to include discussion of domestic issues. It’s a pretty sure bet that health care will come up. And with a town hall format that has voters rather than moderators asking questions, this debate may offer a unique opportunity to gain insight into how each candidate’s policies could affect real people.

Larry Levitt, MPP

I will not be in the live audience tonight. But with the hope that some in the audience read the JAMA Forum, I offer a couple questions here that, ideally, each candidate will address, along with the backstories to provide some context.

Questions for Governor Romney

Question: You have proposed a premium support plan for Medicare, arguing that a competitive market will save money for the federal government. If it does work out that way, what will the effect be on Medicare beneficiaries?

Backstory: The premium support plan proposed by Governor Romney would have the federal government provide a fixed payment to beneficiaries that could be used to purchase a private insurance plan or buy into the traditional Medicare program. If the chosen plan costs more than the fixed payment, the beneficiary pays the difference. The federal government saves money if the fixed payment is less than what it now costs to provide traditional Medicare coverage. And if that’s the case, seniors will face the choice of paying more to enroll in traditional Medicare or enrolling in a less expensive private insurance plan. A key detail here, as yet unspecified, is how much the premium support payment provided by the federal government will be and how fast it will grow over time. Depending on how the plan works, the effects could vary significantly by geographic area.

Question: You have indicated that you want to provide protections for people with preexisting health conditions. How would you do that?

Backstory: Starting in 2014, the Affordable Care Act (ACA) prohibits insurance companies from denying coverage to people with preexisting conditions or charging them higher premiums than people who are healthy. Governor Romney has said he will seek to repeal the ACA and instead proposed to “prevent discrimination against individuals with pre-existing conditions who maintain continuous coverage.” This is already the case for people with employer-based insurance, though not for people with individual coverage. However, even for people moving from employer to individual insurance, there are currently no federal restrictions on how much people with preexisting conditions can be charged. Governor Romney also recently suggested that Americans who are uninsured should have a “choice” to be covered, even if they have a preexisting condition. He did not, however, specify the details of how that choice would work, including how much people could be charged.

Questions for President Obama

Question: The health reform law you signed into law includes $716 billion in savings in the Medicare program over the next 10 years. Do you think more money can and should be saved in Medicare on top of that to reduce the deficit? If so, can it be done without beneficiaries paying more or getting less?

Backstory: The Congressional Budget Office (CBO) projects that under the ACA Medicare will spend $716 billion less over the next 10 years than it would otherwise. Spending will still increase, just more slowly than if the ACA had not passed. The savings come overwhelmingly from lowering amounts paid to private insurers under the Medicare Advantage program and reducing the rate of growth in hospital payments. Benefits provided to beneficiaries improve under the ACA, with the elimination of the “doughnut hole” coverage gap in the Medicare drug benefit and expanded coverage of preventive services. With upcoming budget debates, however, the question is what (if any) further changes will be made to Medicare to reduce the deficit and maintain the solvency of the program’s hospital trust fund. Can and should additional Medicare savings be achieved without diminishing benefits or increasing costs for beneficiaries?

Question: The automatic budget cuts set to go into effect next year protect Medicaid. Should Medicaid similarly be protected in upcoming budget deliberations?

Backstory: The imminent “sequestration” budget reductions include across-the-board cuts in federal spending. However, during the final negotiations over the debt deal that led to the reductions, Medicaid was exempted from the cuts, reportedly at the insistence of the Obama Administration. Now, with a host of budget issues back on the table—the sequestration, expiration of the Bush-era tax cuts, and automatic reductions in physician payments under Medicare set to go into effect—a variety of spending and tax changes may be considered over the next several months as part of an effort to reduce the deficit. President Obama has said he opposes Republican proposals to transform Medicaid into a block grant, which would reduce federal spending significantly while giving states greater flexibility. It would likely lead to fewer people covered by Medicaid and more Americans uninsured. In contrast, the ACA expands Medicaid starting in 2014, with the federal government picking up virtually all of the extra cost if states choose to implement the expansion. But could budget talks lead to other changes in Medicaid?

These are all, to be sure, hard questions to answer, requiring nuance and explanations that are difficult in an age of split screens and rapid fire charges and countercharges. Indeed, presidential debates these days are a far cry from the historic Lincoln-Douglas senate debates of 1858, where each candidate spoke uninterrupted for a total of 90 minutes. But the answers to these questions could go a long way toward helping Americans understand the dramatically different visions these 2 candidates have for the future of health care.

About the author: Larry Levitt, MPP, is Senior Vice President for Special Initiatives at the Kaiser Family Foundation and Senior Advisor to the President of the Foundation. Among other duties, he is Co-Executive Director of the Kaiser Initiative on Health Reform and Private Insurance.