Role of Federal Government Drives Health Care Reform Debate Between Presidential Candidates

The national debate regarding health care reform has revealed sharp differences in how the two major presidential candidates view health care, making this November's presidential election a potential turning point in how the nation proceeds with health care reform.

The Patient Protection and Affordable Care Act is a major achievement of President Obama's administration, and he has promised to leave the law largely intact if re-elected. At the same time, former Massachusetts governor and Republican presidential nominee Mitt Romney has vowed to repeal and replace most parts of the Affordable Care Act, saying it amounts to a government takeover of health care.

"I cannot remember in the last two decades any election as starkly different about the government's role in U.S. health care than this election," says Robert Blendon, Ph.D., professor of health policy and political analysis at the Harvard School of Public Health.

The Affordable Care Act represents Obama's plan and vision for health care reform in this country. Some of the key components of that plan are that "young Americans entering the workforce (now) can stay on their parents' plans," according to the 2012 Democratic platform (32-page PDF; About PDFs).

In addition, "Insurers can no longer refuse to cover kids with pre-existing medical conditions." And, "Insurance companies will no longer be able to arbitrarily cap and cancel coverage or charge women more simply because of their gender. People with private insurance are getting preventive services like cancer screenings, annual well-woman visits, and FDA-approved contraception with no out-of-pocket costs," says the Democratic platform.

The Affordable Care Act also is expected to extend health insurance coverage to 32 million more people during the next few years through a combination of insurance reforms, state-based insurance "exchanges" and program expansions. This includes a mandate that individuals carry insurance by 2014 or face a financial penalty. Low-income individuals and small businesses would be eligible for subsidies to pay for the insurance.

However, extending coverage to millions more people will place more pressure on the nation's primary care practices. Thus, the Affordable Care Act has been paired with the American Recovery and Reinvestment Act of 2009 to make several key investments in primary care and the primary care infrastructure to strengthen the role of primary care in the nation's health care system. According to the Democratic platform, "Democrats will continue to fight for a strong health care workforce with an emphasis on primary care."

For example, the Affordable Care Act provides a 10 percent increase in Medicare payments for primary care services provided by primary care physicians from 2011 to 2015. It also sets Medicaid payment rates for primary care services and some preventive health care equal to 100 percent of Medicare payment rates in 2013 and 2014.

The health care reform law takes other steps to revitalize the nation's primary care base by funding the National Health Service Corps and the nation's community health centers. In addition, the Affordable Care Act reauthorizes Title VII health professions grants for family medicine, the only federal program that provides funds for the education and training of family physicians.

"In my first term, we have made historic strides, more than doubling the size of (the) National Health Service Corps and supporting loan repayment and other incentive programs for primary care physicians," Obama said in a statement. "Because of my health reform law, Medicare now provides a bonus to compensate family and primary care doctors, and Medicaid reimbursements for primary care will increase."

One of the goals of the Affordable Care Act is to move U.S. health care from a volume-based to a value-based model. To help accomplish that goal, the health care law has established a CMS Center for Medicare and Medicaid Innovation to test innovative health care and delivery models, such as the patient-centered medical home (PCMH).

Although Romney has called for the repeal and replacement of the Affordable Care Act, he has not proposed a health care plan of his own.

"Romney has made it clear that he is not laying out at the moment any complete alternative," says Blendon. "His campaign is to get rid of the existing (law) and start over, and to start over by looking at issues piece by piece.

"His argument is we can't go forward with the existing law, and he is not going to worry about alternatives as long as the (Affordable Care Act) is on the legislation train to be implemented," adds Blendon.

Recently, however, Romney clarified his position on the Affordable Care Act somewhat, stating, "I'm replacing it with my own plan …. I'm not getting rid of all of health care reform, of course. There are a number of things that I like in health care reform that I'm going to put in place.

"One is to make sure that those with pre-existing conditions can get coverage. Two is to assure that the marketplace allows for individuals to have policies that cover their family up to whatever age they might like. I also want individuals to be able to buy health insurance on their own, as opposed to only being able to get it on a tax-advantaged basis through their company," he said during an interview on Meet the Press.

In calling for repeal of the Affordable Care Act, the 2012 Republican platform (62-page PDF; About PDFs) says the health care law was "never really about health care, though its impact upon the nation's health is disastrous. From its start, it was about power, the expansion of government control over one-sixth of our economy and resulted in an attack on our Constitution by requiring that U.S. citizens purchase health insurance."

As of AAFP News Now's publication deadline, Romney had not put forth a position on the PCMH or talked about how to address the shortage of primary care physicians. Both Romney and Obama agree on the need to increase access to insurance coverage, but they fundamentally disagree on how to accomplish that goal.

"The Republican view is that they should not be in the business of fixing pieces of health care with national legislation. Markets, private companies and private sector leaders should deal with these issues," says Blendon.

The Republican platform addresses both the Medicaid and Medicare programs, saying that "the first step is to move the two programs away from their current unsustainable defined-benefit entitlement model to a fiscally sound defined-contribution model."

"This is the only way to limit costs and restore consumer choice for patients and introduce competition; for in health care, as in any other sector of the economy, genuine competition is the best guarantee of better care at lower cost," the Republican platform states.

The Republican plan for Medicaid calls for block grants, which would give states fixed amounts of money to run their Medicaid programs. It also would convert Medicare into a "premium support" program for future Medicare beneficiaries -- those who are 55 and younger -- by providing them with government-backed vouchers so they could purchase insurance benefits through private insurers. Beneficiaries also would have the option of staying in the traditional Medicare program.

Obama opposes plans to convert Medicaid to a block grant program or turn Medicare into a premium support program. "Democrats adamantly opposed any efforts to privatize or voucherize Medicare," the Democratic platform says.

Romney also has made various statements that adhere to the Republican positions on health care, thereby offering some insight into his thinking about health care reform. According to a summary put together by Kaiser Health News, Romney supports the concept of "market dynamics" that include provider performance ratings, cost comparisons for procedures and reducing the number of uninsured to improve the nation's health care delivery system.

Romney also endorses "efforts to find an alternative to the fee-for-service payment model," according to the Kaiser Health News summary. In addition, Romney favors "ending tax discrimination against the individual purchase of insurance" and has "suggested allowing tax deductions for people who obtain health insurance on their own." At the same time, Romney supports allowing individuals and small businesses to join together to buy insurance, according to the Kaiser summary.

In addressing medical liability, Romney favors caps on noneconomic damage awards in medical malpractice lawsuits and the provision of funds for states to develop health courts and other alternative means for dealing with medical liability, the Kaiser Health News summary says.

The Affordable Care Act, by contrast, fails to address comprehensive tort reform. It does, however, authorize $50 million for the next five years for HHS to award project grants to states to develop, implement, institute and evaluate alternatives to the current tort litigation system for resolving disputes about injuries caused by physicians and other health care providers.

In his statement, Obama said he supports "reforms to rein in frivolous lawsuits while ensuring that patients get the best care." He also said, however, "I oppose arbitrary caps that will keep seriously injured people from getting the help they need without having a real impact on costs."