By ROBERT RICH
The future of the American health care system is an area where the contrast and choice between President Barack Obama and Gov. Mitt Romney could not be clearer.
Romney's plan calls for:
— Repeal of the Affordable Care Act ("Obama Care");
— Giving control of the design, financing and delivery of health care to each individual state;
— Transforming Medicaid (currently an intergovernmental federal/state program) to a program exclusively controlled by the states;
— Increasing competition between health insurance companies across state lines;
— Increasing individual choice and autonomy concerning health care; and
— Placing an emphasis on reducing and controlling expenditures on health care.
Putting aside the fact that a President Romney cannot by himself repeal the Affordable Care Act without the consent of Congress and that Congress cannot repeal this legislation without the consent of the president, let us consider what the likely impact of the Romney plan will be.
Medicaid currently represents the single largest expenditure of any state government (or the second largest expenditure at least), and governors are clamoring for relief from this "burden."
Romney has said that the current level of federal investment will be capped and transferred to the states with a possible 1 percent increase per year. The result is very likely to result in an increase in the number of uninsured individuals in each state.
As a country, we are likely to move from the current level of almost 50 million individuals who are uninsured to 60 or 65 million who will be uninsured. More individuals will declare bankruptcy due to medical expenditures, and the number of people in poverty also will increase.
In addition, states will be forced to cut back on services currently provided to reduce and control expenditures. Some likely candidates for cuts will be preventative medicine for women and children and long-term care for the elderly, since Medicaid currently pays for a large share of nursing home care.
Since each state can design its own Medicaid program in contrast to the current intergovernmental program where each state is obligated to provide certain core services, there are likely to be great disparities and inequalities between the states.
Or, one could argue that the states will adopt programs that are consistent with what they can afford and what is consistent with the preferences of their citizens. Moreover, increased competition between insurers will result in lower premiums and lower overall health care expenditures.
There is no doubt that if Romney becomes president and if Congress adopts his health care plan, the American health care system will be substantially transformed from its current state and radically transformed from the system envisioned under the Affordable Care Act. Medicaid will become a state-controlled and administered program, the scope of services will be reduced, the number of people who are uninsured will increase and overall health care expenditures will decrease.
In contrast, Obama's vision is for full implementation of the Affordable Care Act as of Jan. 1, 2014, which calls for:
— Providing health insurance for 31 million people who are currently uninsured;
— Expanding the scope of Medicaid to include people at 125 percent of the federal poverty level by providing additional federal funding to finance this change;
— Eliminating pre-existing conditions as a reason to deny insurance to individuals;
— Eliminating the ability of insurance companies to cancel insurance for those who become ill;
— Controlling rates for health insurance premiums; and
— Decreasing the costs of prescription drugs for senior citizens.
Individuals are mandated to purchase health insurance or have it provided by their employer or pay a "tax" if they do not comply.
The trade-offs for the Obama plan are also very clear. Individual autonomy is limited through the mandate to purchase health insurance. State Medicaid programs will be implemented in the context of a comprehensive overall federal framework, and expenditures on health care will definitely increase.
Moreover, regulation of insurance and prescription drug companies also will significantly increase.
The first presidential debate underscored the fact that budgets represent policy choices and preferences. The candidates have two very different sets of choices on what the future of the American health care system should be. These choices have dramatic consequences for the states, the uninsured and the level of expenditures that we, as a country, will undertake for our health care.
Robert F. Rich is a retired professor of law, medicine, political science and public health and the retired director of the Institute of Government and Public Affairs at the University of Illinois.