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October 24/31, 2012

The Health Policy Election

Author Affiliations

Author Affiliations: Indiana University School of Medicine, Children's Health Services Research, Indianapolis (Dr Carroll); and VA Boston Healthcare System, Department of Veterans Affairs, and Boston University, Boston, Massachusetts (Dr Frakt).

JAMA. 2012;308(16):1633-1634. doi:10.1001/jama.2012.13667

Much is at stake in the 2012 presidential election. President Barack Obama's vision and former Governor Mitt Romney's vision differ across many domains, but perhaps most starkly in the area of health policy. Fundamentally, the candidates disagree on the role of government as the guarantor of affordable access to health insurance, as evidenced by their plans for private insurance markets, Medicare, and Medicaid.

Private Insurance

Obama's vision is reflected in the Affordable Care Act (ACA); Romney wants to repeal it. The ACA makes significant changes to private insurance regulation. The individual market will be remade, with subsidies available to families with incomes up to 400% of the federal poverty level. Insurance companies will no longer be permitted to deny coverage due to preexisting conditions or be able to charge more to those with preexisting conditions. Other changes include elimination of lifetime and annual limits, a floor on coverage generosity, and a requirement for family policies to cover dependent children until age 26 years. These changes are expected to increase the number of privately insured by 16 million.1

Romney's repeal of the ACA would reduce federal spending on coverage expansion but also the number of people with insurance. He has proposed components of a replacement plan. One would be to forbid insurers to deny coverage due to preexisting conditions for those with continuous coverage, something the 1996 Health Insurance Portability and Accountability Act (HIPAA) already does for individuals in the group market and transitioning from it to the individual market.2 However, neither HIPAA's nor Romney's protections would extend to the estimated 89 million individuals who have coverage gaps. Also, neither guarantees that coverage would be affordable.

Romney has also proposed to increase choice and competition by relaxing insurance regulations. These include allowing insurance to be sold across state lines, permitting health savings account funds to be used for premiums, and equalizing the tax treatment of individually and group-purchased health plans. Although these reforms might help some uninsured individuals obtain coverage, they are neither likely nor designed to reduce uninsurance as much as the ACA.


The candidates also differ in how they think Medicare ought to be structured. The president wants to retain the current defined benefit nature of the program, whereas Romney wants to convert it to a defined contribution model. The former is an explicit commitment to affordable access to coverage; the latter is not.

Within the current structure, the ACA would begin to slow the increase in health care spending in the Medicare program by, among other things, reducing payments to Medicare Advantage plans, encouraging development of accountable care organizations, and more broadly bundling payments (Figure). Many of the payment reforms are designed to incentivize more efficient practice of care, even though some are less targeted payment cuts. Should these measures fail to keep Medicare growth below one percentage point above that of the overall economy, an Independent Payment Advisory Board will be tasked with defining spending reduction recommendations with fast-track legislative authority. All told, these reforms are projected to save $716 billion over the next decade, extending the life of the Medicare Part A Trust Fund by 8 years, to 2024.3

Figure. Federal Medicare, Medicaid, and Private Insurance Subsidy Spending Under Obama and Romney Proposals
Figure. Federal Medicare, Medicaid, and Private Insurance Subsidy Spending Under Obama and Romney Proposals

Obama budget figures are directly from Congressional Budget Office (CBO) documents. New private (Obama) reflects expenditures for coverage through health insurance exchanges but not any offsetting revenue. Romney budget figures reflect CBO estimates of the budget resolution developed by his running mate Rep Paul Ryan, passed by the House in 2012, and endorsed by Romney with 1 exception: the ACA Medicare cuts that Romney has pledged to reverse are added back to these estimates. There are no available estimates of federal spending associated with Romney's proposals for the private insurance market. Additional details are available from the authors.
Sources: The Long-Term Budgetary Impact of Paths for Federal Revenues and Spending Specified by Chairman Ryan, CBO (2012); The Path to Prosperity, House Budget Committee, Paul Ryan (March 20, 2012); Letter to House Speaker John Boehner, CBO (July 24, 2012); 2009, 2010, and 2012 Long Term Budget Outlook, CBO (June 2009, 2010, and 2012); and Updated Budget Projections, Fiscal Years 2012 to 2022, CBO (March 2012).

By repealing the ACA, Romney would eliminate these savings, increase Medicare spending in the near term, and reduce the time until the fund is exhausted. He would also increase the eligibility age of Medicare from 65 to 67 years. Although this would save the federal government an estimated $5.7 billion per year, it would result in twice that cost to affected seniors and businesses and other programs that would otherwise cover them.4

Romney has also proposed restructuring Medicare with a program of premium support that would apply to those currently younger than 55 years. The program's fee-for-service plan and private plans would bid their per-enrollee cost to provide the actuarial equivalent of the Medicare benefit. A defined contribution equal to the second least expensive plan would be provided to beneficiaries. If beneficiaries chose a more expensive plan, they would have to pay the difference out of pocket. What remains unclear is what would happen under such a plan if Medicare growth rates did not stay below the proposed target of half a percentage point above the rate of growth of the overall economy. Moreover, while such a plan might save the government money, some argue that it will not bend the health care cost curve and may not include many important safeguards for beneficiary welfare.5 Regardless, it will not affect Medicare spending for at least a decade.


The 2 candidates' Medicaid plans are quite different. The president will expand the program; Romney would cut it back. The ACA was designed to provide Medicaid to individuals whose incomes are less than 138% of the federal poverty level. If implemented in all states, an additional 16 million people would be covered by the program at a cost to the federal government of $444 billion through 2019. To help bolster clinician participation, reimbursement rates are also being increased. While initially mandatory, this expansion became optional through a Supreme Court ruling in June, and some Republican governors have pledged not to participate.

Romney would eliminate all these changes. Instead, he would institute a block grant program. States would be free to “innovate” to find novel ways to cover poorer constituents within the constraints of the resources afforded by the block grants. Many federal restrictions on Medicaid would be lifted, allowing states to save money, if they wished, by covering fewer people or providing fewer benefits.

Savings from this Medicaid proposal come from severely reduced future spending at the federal level. Romney has expressed support for the spending targets in his running mate Representative Paul Ryan's 2013 federal budget, which held Medicaid growth to that of overall inflation. According to the Congressional Budget Office, by 2022, Medicaid and Children's Health Insurance Program spending would only be $322 billion, just $4 billion more than was spent in 2009.6 Without some significant and uncertain innovations, this may require millions of persons to be removed from Medicaid rolls, or a significant reduction in benefits.


Even though their visions for private and public coverage differ in many ways, the overarching distinction between the candidates is how they prioritize coverage expansion vs reduced federal spending on health care. As such, it is the focus of the ACA, which will substantially increase the numbers of insured through an expansion of Medicaid and the (subsidized) private health insurance market. Notwithstanding his pledge to reverse the ACA and spend more on Medicare in the near term, Romney's proposals generally favor spending reductions, withdrawing federal support for private insurance expansion, drastically reducing Medicaid spending, eliminating Medicare coverage for 65- and 66-year-olds, and restructuring Medicare into a defined contribution program for those currently younger than 55 years. These are major differences and will have enormous effects on all facets of the health system and the number of uninsured, as well as federal costs. On health policy, as well as other areas, voters have a real choice in November.

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Article Information

Corresponding Author: Aaron E. Carroll, MD, MS, Indiana University School of Medicine, Children's Health Services Research, 410 W 10th St, HITS Bldg, Ste 1020, Indianapolis, IN 46202 (aaecarro@iupui.edu).

Published Online: October 11, 2012. doi:10.1001/jama.2012.13667

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Disclaimer: The views expressed by the authors do not necessarily reflect those of the Department of Veterans Affairs, Boston University, or Indiana University School of Medicine.

Congressional Budget Office.  Updated Estimates for the Insurance Coverage Provisions of the Affordable Care Act. http://www.cbo.gov/sites/default/files/cbofiles/attachments/03-13-Coverage%20Estimates.pdf. March 2012. Accessed September 13, 2012
The Henry J. Kaiser Family Foundation.  How Private Health Coverage Works: A Primer, 2008 Update. http://www.kff.org/insurance/upload/7766.pdf. April 2008. Accessed September 13, 2012
Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds The Boards of Trustees.  2012 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. http://www.treasury.gov/resource-center/economic-policy/ss-medicare/Documents/TR_2012_Medicare.pdf. April 2012. Accessed September 13, 2012
The Henry J. Kaiser Family Foundation.  Raising the Age of Medicare Eligibility: A Fresh Look Following Implementation of Health Reform. Kaiser Family Foundation Medicare Policy. http://www.kff.org/medicare/upload/8169.pdf. July 2011. Accessed September 13, 2012
Aaron HJ, Frakt AB. Why now is not the time for premium support.  N Engl J Med. 2012;366(10):877-87922276779PubMedGoogle ScholarCrossref
Congressional Budget Office.  The Long-Term Budgetary Impact of Paths for Federal Revenues and Spending Specified by Chairman Ryan. http://cbo.gov/sites/default/files/cbofiles/attachments/03-20-Ryan_Specified_Paths_2.pdf. March 2012. Accessed September 13, 2012