The top Republican presidential candidates have all called for repealing President Obama's health care initiative, but that unity breaks down when it comes to their plans for what should replace it.
The candidates bring varying degrees of familiarity with the complex issue. Mr. Obama cited former Massachusetts Gov. Mitt Romney's health care experiment as an inspiration for the national law. Former House Speaker Newt Gingrich once supported the individual mandate requiring all Americans to purchase coverage, and Texas Gov. Rick Perry has overseen what analysts say is one of the most troubled health care systems in the country.
Mr. Romney may have the most detailed plan for Medicare. He has called for states to enact their own reforms, for customer incentives to buy coverage and for tort reform. Rep. Ron Paul, a medical doctor, may have the most sweeping plan: an end to any new Medicare patients.
Former Utah Gov. Jon Huntsman Jr., who enacted health care reform in Utah, proposes eliminating the employer tax credit for purchasing insurance — an idea that could drastically change the way Americans obtain coverage. Mr. Perry has said states should be able to opt out of Medicare and proposes to block-grant Medicaid, but has offered little more than that.
"I think some of the candidates probably have a more in-depth understanding of the issues," said Amy Lischko, a professor of medicine at Tufts University. "If you were a governor who did anything with respect to health care, you kind of understand how complicated it is. Huntsman and Romney — I feel like they probably have the best knowledge. Perry, his issues are sort of different."
All but Paul
All of the top six candidates agree on repealing Mr. Obama's signature initiative, and all want to trim Medicaid costs. Except for Mr. Paul, they all say that at least some parts of Medicare should be turned into a voucherlike system allowing seniors to purchase private plans.
The field also supports expanding health savings accounts and allowing insurers to sell plans across state lines.
But the candidates vary when it comes to the degree of detail in their plans and how knowledgeable they are about health care policy.
In a candidates debate last week, Mr. Romney fired off four smooth bullet-point solutions that included health savings accounts and incentives for states to work on their own plans.
Earlier this month, he proposed significant cuts to Medicare and Medicaid in the future, while preserving benefits for current enrollees. The plan is similar to a budget released last spring by Rep. Paul Ryan, Wisconsin Republican, that proposed converting Medicaid into block grants to states and turning Medicare into a voucher system — though Mr. Romney's plan would give seniors the option of remaining on traditional Medicare or purchasing private pla>ns.
"If I am the nominee and I get the chance to debate President Obama, this is what we're going to be talking about," he told a crowd at the University of Michigan in May as he defended his own experiment in Massachusetts. "I'm confident that when considering those two plans, the American people will say the Mitt Romney U.S. reforms, that's a lot better than Obamacare."
Not a sound bite
Also offering one of the more detailed plans, Mr. Gingrich suggests state-based insurance pools for high-risk patients, reinforcing laws against discrimination based on pre-existing conditions, reforming Food and Drug Administration regulations and converting to electronic medical records to reduce fraud.
He complained to the debate moderator last week that half a minute was not nearly enough time to explain his plan.
"To say in 30 seconds what you would do with 18 percent of the economy, life and death for the American people, a topic I've worked on since 1974, about which I wrote a book called 'Saving Lives and Saving Money' in 2002, and for which I founded the Center for Health Transformation, is the perfect case of why I'm going to challenge the president to seven Lincoln-Douglas-style three-hour debates," Mr. Gingrich said to cheers from the audience.
As the only medical professional in the GOP field and the strongest advocate for the free market, Mr. Paul focused on stronger doctor-patient relationships and ending government insurance programs in favor of health savings accounts.
He has his own ideas for Medicare. Instead of turning it into a voucher system, he wants to end it for those not yet enrolled. He also proposes keeping down the costs of medical-malpractice insurance not by capping awards, but through a tax credit for "negative outcomes" insurance to compensate patients for medical mistakes.
Rep. Michele Bachmann of Minnesota says insurers should be allowed to sell plans across state lines and has called for tax breaks for all medical-related expenses as well as tort reform. She also has supported reducing future Medicare benefits for Americans younger than 55 and allowing small businesses to band together through trade associations to purchase cheaper insurance. She voted for Mr. Ryan's budget, but later said it could hurt seniors.
Back to the states
Other candidates have said less about exactly how they would improve health care, whether or not Mr. Obama's law was repealed.
Mr. Perry proposes a gradual raise in the Medicare eligibility age, but his "cut, balance and grow" economic plan offers few other details. He told the debate moderator that seniors should be given more coverage options, and then touched on the health care topic tied most closely to his role as governor: Medicaid.
"You send it back to the states and let the states figure out how to make Medicaid work because, I'll guarantee you, we will do it safely, we will do it appropriately, and we will save a ton of money," he said.
Although he has supported tort reform, Mr. Perry's record on health care mainly involves resisting government health care programs and their impact on Texas, which continues to log the highest uninsured rate of any state. He tried to opt his state out of Medicaid last year after repeatedly resisting the program's rules. He has cited the 10th Amendment in his arguments that states should be able to opt out of Medicare and provide their own means of health care for the elderly.
He also threatened this year that he would veto a bill authorizing the state to begin setting up an insurance exchange, a requirement under the federal health care law.
Former corporate CEO Herman Cain pointed to a health care plan championed by Rep. Tom Price, Georgia Republican and a physician, as his "starting point." The Empowering Patients First Act preserves the system of employer-sponsored insurance, but includes tax breaks for purchasing insurance in the individual market, among other reforms.
As a business owner who bought coverage for his employees and as a survivor of cancer found in his colon and liver a few years ago, Mr. Cain brings a markedly different background to the field. "I am walking proof that we have the best health care system in the world," he told reporters this month. "I was able to make some decision about my cancer treatment. That's why I am alive today."
The one unifying position all have, however, is a repeal of the Democrats' moves. The position is sure to curry favor, at least in the primaries, as more Americans now say they are opposed to the law than in favor of it.
"I think that repealing the Affordable Care Act is just such a clear call and such a clear policy proposal that it's almost standing in as a symbol on what candidates would do on health care," said Elizabeth Rigby, a professor of public policy at George Washington University. "It's such a generic position that it's easy for people with many, many, many different priorities to agree to it."
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