Two issues are now front and center. The first is Obama’s Affordable Care Act, passed against Republican opposition in 2010. The biggest applause line at any Republican rally this year has been the pledge to repeal “Obamacare.” The law has come to symbolize all that conservative Republicans believe is wrong with Obama’s presidency, including the cost of the legislation and the government’s role in the health-care market. Obama has stressed the law’s consumer protections to win greater support for it, but he has made little progress. The measure stirs passions among Republicans who hate it; Democrats who like it feel far less passionate about it.
The other issue is Medicare. It flared up in August after Romney chose House Budget Committee Chairman Paul Ryan as his running mate. Ryan’s federal budget blueprint calls for the government to eventually provide fixed payments for Medicare beneficiaries, who could then buy insurance on the private market.
Romney’s team jumped on Medicare immediately after Ryan’s selection, trying to put Obama on the defensive by charging that it was he who would undermine the program.
Romney said Obama had cut $716 billion from Medicare to help pay for his health-care overhaul. The reductions come from payments to hospitals and other providers, not from benefits to seniors. And the Ryan budget includes the same reductions.
— Dan Balz
Here are Obama and Romney’s positions on health care, broken down by subject:
AFFORDABLE CARE ACT
Although Obama has said he would be open to making small changes in the 2010 health-care law, he would vigorously defend its main planks and press for its implementation in a second term.
One of his biggest challenges: trying to increase cooperation from the states, several of which adamantly oppose the law. The legislation calls on states to expand their Medicaid programs, but the Supreme Court ruled in June that the federal government can’t penalize states for refusing to do so. Nearly a dozen governors say they are considering not expanding their programs, and some might seek greater flexibility in return for participating.
Obama has been silent on how much leeway he might provide to entice reluctant governors. His aides predict that almost all the states will ultimately go along with the Medicaid expansion, because the federal government will pay most of the costs.
Obama also will prod states to create insurance exchanges. Under the law, federal authorities will have to set up and run an exchange if a state declines to do so.
The president has expressed some support for changing the medical malpractice system. Although he opposes limits on jury awards, he is pressing ahead with pilot programs to test whether alternative systems for resolving malpractice claims can cut down on lawsuits.
Romney opposes the health-care law and says states should fashion their own policies to deal with the uninsured.
He has cited the Massachusetts health-care overhaul as an example of what states can do.
He says he would move to repeal the Affordable Care Act. He also has talked about issuing waivers to let states opt out of specific provisions. But he would need a sympathetic Congress to succeed in getting rid of the law.
Romney has spoken favorably about a few of its provisions. He has said he would like to allow adult children to stay on their parents’ health plans “up to whatever age they might like.” The law allows children to stay on the plans up to age 26. And he has said that insurers should cover people with preexisting conditions.
His campaign has clarified that he is referring to preexisting-condition coverage for people with no gaps in their health insurance coverage. That’s a lower standard than in the health-care law.
Romney has proposed a number of health-care changes long supported by Republicans. He wants, for example, to provide tax breaks to individuals who buy coverage on their own through the private market, and allow the sale of insurance across state lines. He also supports limiting some types of damages in medical malpractice suits.
Obama rejects Republican proposals to turn Medicare into a program in which seniors receive fixed payments to buy coverage from insurers or traditional Medicare. He says such a change would shift costs to seniors.
Obama says the health-care law will help rein in Medicare spending. It creates an independent board that will make suggestions on cutting payments to providers if the program grows too fast. The board won’t be allowed to raise premiums or reduce benefits.
The law also creates incentives for doctors, hospitals and other providers to coordinate care and emphasize prevention in an effort to lower costs and improve quality.
Overall, the law is expected to reduce Medicare spending by $716 billion over 10 years by cutting back on payments to providers and Medicare Advantage plans. The savings, while helping to fund the coverage expansion, also would extend the solvency of Medicare’s hospital trust fund through 2024.
During failed budget negotiations with Republicans in 2011, Obama reportedly considered raising the eligibility age for Medicare from 65 to 67. But he has never publicly supported the idea.
In his latest budget, Obama proposed cutting $188 billion from Medicare over 10 years, mainly by requiring drug companies to provide larger rebates to the government.
Romney says Medicare’s growth must be slowed to bring the federal budget deficit under control. He argues that the open-ended entitlement program should be replaced with “a competitive, market-oriented” approach. He wants to transform Medicare into a “premium-support” program that would give seniors a fixed payment to buy private coverage or a government plan similar to what exists now.
If seniors bought a more expensive plan, they would have to pay the difference between the fixed amount they receive and the premium; if they bought a cheaper plan, they could keep the difference. Romney hasn’t said how the amount of the fixed payment would be adjusted annually as health-care costs rise.
He has said he would leave the program untouched for people older than 55. If the health-care law were repealed and the $716 billion restored, however, today’s Medicare beneficiaries would face higher premiums in addition to greater out-of-pocket costs for drugs and preventive care.
Romney has suggested other changes to keep the program solvent.
“What I do in my Medicare plan for younger people coming along is say this: We’re going to have higher benefits for low-income people and lower benefits for high-income people,” he said in a recent “60 Minutes” interview.
Obama staunchly opposes Romney’s proposal to turn Medicaid into a block grant that probably would offer states less federal money in exchange for more freedom in how they spend it.
He argues that Medicaid provides a key safety net, a position that’s consistent with the health-care law’s broad expansion of the program.
But he hasn’t opposed all Medicaid money-saving efforts. During the 2011 budget negotiations with Republicans, he suggested reducing the federal contribution to the program by tens of billions of dollars over 10 years by changing the way the federal government pays states.
After an outcry from liberal groups, Obama scaled back the idea. He included a version in his proposed budget for fiscal 2013 that would reduce federal spending on Medicaid by less than 1 percent.
Romney has proposed a major change to this government entitlement program that provides health insurance to the poor and disabled.
Currently, the program is funded by the federal and state governments, and anyone who meets federal eligibility requirements — or state standards, if those are more generous — may enroll. Under Romney’s plan, however, states would receive set amounts, or block grants, from the federal government to disburse largely as they wish.
Conservatives, who have long supported Medicaid block grants, say the approach would not only save taxpayers money but also encourage states to innovate and tailor their programs to the unique needs of their populations.
Romney has said he would hold Medicaid growth to the rate of inflation plus one percentage point, a spending slowdown that he says would save the country $100 billion a year.
Obama is a strong supporter of abortion rights. If a Supreme Court vacancy were to come up during a second term, he would be likely to appoint a justice he believed would be sympathetic to upholding Roe v. Wade, the decision that legalized abortion nationwide.
He is a proponent of Planned Parenthood, and has moved to block efforts by some in Congress and legislatures in states such as Indiana and Texas to ban Planned Parenthood and other abortion providers from receiving federal Medicaid funding.
Planned Parenthood uses the money to provide health screenings such as mammograms; by law, the group cannot use federal funding for abortions.
Obama supports permitting federal funding of international aid groups that use money from non-U.S. sources to promote or provide abortions. (U.S. funding cannot be used to pay for abortions.) One of Obama’s first acts as president was to reverse a ban on the funding of such groups, a prohibition known as the Mexico City policy.
Romney, who once backed abortion rights, says he now thinks the procedure should be illegal in most circumstances — except in the cases of rape, incest or to save the mother’s life.
He says the Roe v. Wade ruling was “a case of blatant judicial activism that took a decision that should be left to the people and placed it in the hands of unelected judges,” according to his Web site. He wants the decision overturned.
Romney supports cutting off federal funding to Planned Parenthood because of its role as the nation’s largest abortion provider.
And like other Republican presidential candidates before him, he backs the reinstatement of the Mexico City policy, which would bar the government from providing money to international groups that use non-U.S. funding sources to perform or promote abortion as a method of family planning.
Romney has criticized the Obama administration’s requirement that certain employers that object to birth control on religious grounds must cover it as part of their health insurance plans.
WHAT THE CANDIDATES HAVE DONE ON HEALTH CARE
Obama’s signature domestic accomplishment, the 2010 Affordable Care Act, is the most far-reaching health-care overhaul since Medicare and Medicaid were created in 1965. The law will extend coverage to an additional 30 million Americans.
Millions of these people will be eligible for a newly expanded Medicaid, the state-federal program for the poor and people with disabilities. Millions of others will receive federal subsidies to help buy private health plans on state-based insurance exchanges, which are online marketplaces designed to foster competition among plans.
To achieve this coverage expansion, the law mandates that almost all Americans obtain insurance or pay a tax penalty beginning in 2014. The law also requires that all but the smallest businesses offer health plans to their workers or face fines.
The statute, which the Supreme Court largely upheld in June, will significantly change the way insurers do business, limiting how much they spend on overhead and barring them from rejecting sick people. It also allows parents to keep their children on their insurance plans until they turn 26.
The health-care law aims to curb the rising costs of Medicare, the federal program for the elderly and those with disabilities, through cost-cutting mechanisms, and it closes the gap in Medicare’s prescription drug coverage.
The law also requires that certain preventive services be provided at no out-of-pocket cost. The administration ruled that birth control should be included.
The administration exempted churches from the birth-control requirement. Certain religiously affiliated employers, such as Catholic universities and hospitals, also may opt out — but in those cases, insurers will be required to provide the coverage directly to workers at no extra cost.
Last year, Obama rejected a proposal by the Food and Drug Administration to allow Plan B, also known as the “morning-after pill,” to be sold over the counter without age restrictions.
As governor of Massachusetts, Romney signed into law health-care legislation that became the template for President Obama’s 2010 Affordable Care Act. The law, enacted in 2006, blended several conservative ideas to achieve a long-standing goal of liberals: providing near-universal health insurance.
The law requires almost all residents to have coverage or pay a tax penalty. It also mandates that most employers offer insurance to their workers. And it established a health insurance exchange where people can find affordable coverage that offers a level of benefits approved by the state, and offers subsidies to people who need them.
The statute expanded the state’s Medicaid program for the poor, increasing the amount of income families can earn and still be eligible. It imposed a co-payment for recipients with higher incomes. Federal Medicaid money is a key part of the financing of the law.
When Romney signed the measure, he vetoed several provisions, including the employer mandate. But the state legislature overrode his vetoes and the entire law took effect.
The legislation cut in half the number of uninsured in Massachusetts, according to the Kaiser Family Foundation, a nonpartisan health policy research group. But the state continues to grapple with the rising cost of health care.
In 2005, Romney vetoed a bill to expand access to the morning-after pill, saying it could cause abortions. At the time, Romney, who earlier in his career had supported abortion rights, announced that he opposed abortion. The state legislature overruled his veto.
WHO ARE THEIR ADVISERS?
Nancy-Ann DeParle: On the administration team that pushed through the Affordable Care Act, DeParle was the undisputed quarterback. A veteran of President Bill Clinton’s health-care battles, she is known for emphasizing pragmatism over ideological purity. Although DeParle was promoted from White House health-care czar to Obama’s deputy chief of staff last year, she continues to vet sensitive decisions regarding the law’s implementation.
Jeanne Lambrew: As deputy assistant to the president for health policy, Lambrew oversees the development of regulations to put the health-care law into effect. Since the rules often fill in specific details left vague by the law, the regulation writers make key judgment calls. A former academic who collaborated with former senator Thomas A. Daschle on a book advocating health-care reform, Lambrew combines technical expertise with a focus on overhauling the insurance market.
Kathleen Sebelius: The secretary of health and human services has gamely embraced her role as the public face of the 2010 health-care law. In almost daily public appearances, she extols the law’s virtues. A former governor and insurance commissioner of Kansas, Sebelius also has drawn on her expertise — and her network of friendships in state capitols across the country — to try to persuade state leaders to implement the health-care law.
Donald Berwick, Ezekiel Emanuel and Neera Tanden: None of these policy wonks is still employed by the Obama administration. But Berwick, who once ran Medicare and Medicaid, and Emanuel and Tanden, who were senior advisers, continue to push for the health-care law provisions they once championed from inside the administration. Their particular focus: developing the next raft of proposals to improve health-care delivery at lower costs.
Mike Leavitt: The former Utah governor is heading up Romney’s transition team, but is an experienced hand on health care. He served as secretary of health and human services under President George W. Bush, leading the administration’s rollout of the Medicare Part D benefit. As HHS secretary, he helped Romney implement the Massachusetts health-care overhaul. He’s a supporter of insurance exchanges, a central part of the Obama law.
Tevi Troy: A senior fellow at the conservative Hudson Institute, Troy served as deputy secretary of HHS under Leavitt. Troy is a member of Romney’s Health Care Policy Advisory Group, and has played a role in the candidate’s Jewish outreach efforts. He helped craft the campaign’s response to the Supreme Court decision that upheld most of the health-care law.
Lanhee Chen: Policy director of the Romney campaign, the Harvard-educated heath-policy expert was an adviser to the 2004 Bush presidential campaign and briefly served as deputy HHS secretary. He also wrote on health policy topics for the conservative Heritage Foundation. For a policy wonk, Chen has a reputation for being unusually comfortable in the political spotlight, taking to Twitter regularly to score points on behalf of Team Romney.
Thomas Barker: A partner at the law firm Foley Hoag, Barker specializes in health-care policy and serves on Romney’s health-care policy advisory group. He served in the Department of Health and Human Services during the Bush administration as an adviser to Leavitt, who was HHS secretary. Barker held key roles, including in the implementation of the Medicare prescription-drug benefit. Before that, he served as regulatory counsel to the Massachusetts Hospital Association.
— N.C. Aizenman and Sandhya Somashekhar