A Tale of Two Health Plans

It would be helpful to compare the candidates' views on health care. Yet it is nearly impossible to compare the Affordable Care Act with Mitt Romney’s health care “plan” because, while the reform is a complex, detailed piece of legislation, Mr. Romney’s plan is more of a notion sketched in broad strokes with too little detail to make a comparison (and with too little for the Congressional Budget Office to be able to estimate the costs of his plan).

Affordable Care was hammered out over many months with wide input (and backing) from physicians, hospital administrators, insurers and associations concerned with public health, like the Kaiser Family Fund and the Commonwealth Fund and the American Medical Association. Affordable Care was duly voted into law by Congress after protracted discussion, media attention and public debate. (Tragically, the debate was quickly fouled by the misinformation of detractors and never effectively refuted the Obama administration.)

By contrast, it is unclear exactly who was consulted in the sketch that is Mitt Romney’s plan. Media can still barely discern what the plan entails, which leaves the public clueless and unable to comment. Ironically, the last health care reform Mr. Romney was associated with was the Massachusetts plan while he was governor, on which much of the Affordable Care Act was modeled. Yet he has vowed to repeal Affordable Care, if elected president.

The goals of the Affordable Care Act and Mr. Romney’s plan also are very different.

The Affordable Care Act sought to obtain nearly universal coverage, adding some 30 million people to the ranks of the “insured.” (The great exception is illegal immigrants, who are not covered by the A.C.A. and would remain uninsured.) The reform law endeavored to solve a real problem: millions of uninsured families, including chronically ill adults and children, Americans too sick for insurers to cover at a price these families could afford. The uninsured also included many young, healthy, working Americans who took a risk in not paying for insurance, even though many could afford it. Part of the goal was to include them among the insured as well, to enlarge the insurance pool in order to keep premiums down for everyone.

Mr. Romney’s plan aims to reduce the size of government and its role in health care. That is why he has repeatedly said he would repeal Affordable Care. But repeal would mean undoing popular benefits. These include the reform law’s “fix” of the pharmaceutical subsidy to those elderly in what is known as the “doughnut hole”; parental coverage of young adults through age 26; making it illegal for an insurer to refuse coverage to someone with a pre-existing medical condition or to drop paying customers who become seriously ill. Repeal would mean undoing these benefits or financing them while cutting costs more deeply elsewhere.

Mr. Romney stresses the need for competition to lower medical costs, but private enterprise has ruled health care for decades. Competition has not solved the problem of millions of uninsured Americans, excessive use of hospitals for routine health care and ever-rising medical costs and insurance premiums. Even without the sickest people in the private insurance pools, premiums have gone up steadily.

Mr. Romney’s assumption that private health care is cheaper than government-provided health care has been repeatedly disproved by Medicare, Medicaid and the Veterans’ Administration. Affordable Care combines the work of private enterprise (physicians, insurance companies, hospitals and nursing homes) and government.

After repealing Affordable Care, Mr. Romney’s government would provide vouchers ($8,000 is an annual figure I’ve seen quoted) for buying health insurance—private or government (Medicare). (Paul Ryan’s plan, which is not the same as Mr. Romney’s, would have made private insurance mandatory, for he would dismantle Medicare/Medicaid). Private plans, the Congressional Budget Office has estimated, will cost more than $20,000 by 2022. Would the vouchers keep up with the rising premiums? If not, the elderly would spend an increasing portion of their income on medical costs—from less than a quarter of the average senior income now to half, according to the Kaiser Family Foundation. And were the vouchers too meager, the result would be decreased insurance coverage—the very problem Affordable Care set out to solve.