With Mitt Romney essentially assured the Republican nomination for president, the time has arrived to compare his (supposedly) differing viewpoints on health reform with President Barack Obama's.
As many commentators and policy analysts have recognized, Mr. Romney's Massachusetts health reform law served as the prototype for the federal law derided by Republicans (and now praised by Democrats) as Obamacare. The core of the Affordable Care Act — an individual mandate, guaranteed issuance of insurance, and public health insurance expansion — derived from Governor Romney's achievements.
Interestingly, despite Mr. Romney's avowed opposition to President Obama's health care initiatives, his latest vision for health care shares many elements identical to provisions of the Affordable Care Act.
Both Mr. Romney's current plans for health care and Mr. Obama's Affordable Care Act call for insurance exchanges and subsidies. Both offer high-risk pools (the high-risk insurance program of the ACA has already helped more than 56,000 Americans). Mr. Romney aspires for alternatives to litigation in medical malpractice cases; the ACA has already allocated $50 million in grants to explore alternatives to lawsuits. Both Mr. Romney's and Mr. Obama's health care plans offer purchasing pools, protections for those with pre-existing conditions, and IT interoperability.
However, despite the many similarities between what Mr. Romney would do as president and what President Obama has already achieved, there are several key differences.
First, Mr. Romney proposes a cap on noneconomic damages for medical malpractice. This evidence-based strategy for reducing malpractice premiums and improving physician supply traditionally has been supported by Republicans. Rep. Frank Pallone, a New Jersey Democrat, has suggested that even some Democrats could support a federal noneconomic damage cap if it concentrated on physicians, was higher than the Republican plan offered in HR-5, and had a mechanism to control premium increases. Mr. Obama has yet to personally offer a concrete solution to physicians' medical malpractice concerns.
The second major difference discloses the two candidates' perspectives on the role of states and the federal government in mandating the coverage of health care services. Mr. Romney seeks to limit federal and state standards on health insurance. This could mean reversing the Newborn's and Mother's Health Protection Act (which guarantees at least a 48-hour hospital stay after childbirth), the Mental Health Parity Act (which prohibits group health plans from limiting benefits for mental health compared to medical and surgical benefits), and the Emergency Medical Treatment and Active Labor Act (which ensures public access to emergency services regardless of the ability to pay).
Mr. Romney's push to allow individuals to purchase insurance across state lines would similarly dismantle state regulation of insurance. This policy might lead to a race to the bottom; coverage might become less expensive but would undoubtedly become less comprehensive.
Mr. Romney and Mr. Obama also differ on Medicaid. Mr. Romney wants to change Medicaid funding from an open-ended entitlement to a block grant system, thereby limiting the federal government's exposure to health care costs. The Affordable Care Act, on the other hand, expands Medicaid to 17 million more low-income Americans, at a cost to states and the federal government.
Mr. Romney's fourth distinction from Mr. Obama is his desire to adopt premium support for Medicare. Premium support would convert Medicare from a defined-benefit (where enrollees are guaranteed particular services) to a defined-contribution program. Under the Romney plan, seniors entering Medicare would receive a subsidy to purchase insurance. Seniors purchasing insurance more expensive than the subsidy would be on the hook for the difference. But by making the costs to the federal government more predictable, a premium support plan might bolster the Medicare Trust Fund. Mr. Obama would continue Medicare as a defined benefit.
Both men seek to add means-testing to Medicare, albeit in differing forms. Mr. Romney would have all Americans pay into the Medicare Trust Fund the same percentage rate during their working years, but seniors with higher incomes would receive lower benefits. The Affordable Care Act gives all seniors the same benefits but would require individuals making more than $200,000 to contribute more to the Medicare Trust Fund beginning in 2013.
When examined closely, both health care visions, past and present, are strikingly similar. Mr. Romney's biggest fundamental differences from President Obama are: 1) the dismantling of state and federal health insurance mandates, and 2) the restructuring of Medicaid and Medicare from open-ended entitlements to predictable contributions from the federal government.
Dr. Cedric Dark is an emergency medicine physician at Saint Agnes Hospital and the founder of a health policy consulting firm focused on providing evidence-based health policy. His email is firstname.lastname@example.org.