Q&A: Barack Obama, Mitt Romney's positions on health care as presidential race nears the end

Health care and the reform law that was signed in 2010 have been a pivotal issue all year, and played a major role in the recent presidential debates.

President Barack Obama considers the changes he achieved despite united Republican opposition to be one of his signature legislative achievements.

Both Republican presidential candidate Mitt Romney and his vice presidential running mate Paul Ryan have pledged, if elected, to join House Republicans and repeal the Patient Protection and Affordable Care Act that's gradually being implemented toward full effect in 2014.

But the GOP ticket has endorsed some provisions in the law -- nicknamed "Obamacare" -- that outlawed unpopular insurance company practices. They say they would let young adults stay on their parents' plans and prohibit denial of coverage based on pre-existing conditions -- both signature parts of Obama's reforms.

But without the incentives and expanded customer base the new law mandates, would insurance companies voluntarily agree to end those practices and others that have proven lucrative for so many years?

We asked experts in health-care finance and policy some questions about the health care debate as the campaign draws to its close.

Q. Romney and Ryan make a particularly strong case for restoring $716 billion over 10 years in projected reduced payments to Medicare providers, like hospitals, and Medicare Advantage plans administered by private companies -- not beneficiaries. They have suggested the planned reduction in costs that are part of the reform law would be harmful to senior citizens.

What would be the impact of repealing "Obamacare" on Medicare?

A. The Henry J. Kaiser Family Foundation, a non-partisan health care think tank, has analyzed the impact of repealing just the Medicare provisions of the act and found that the program's hospital trust fund would become insolvent within four years, in 2016, if cost savings reforms were repealed. Part B premiums -- non-hospital outpatient care --would certainly increase, the analysis concluded.

Repeal would also do away with no-co-pay preventive screenings and the phased closing of "the doughnut hole" in coverage for Medicare's Part D prescription drug benefit, keeping the amount left unpaid by Medicare in place.

It would do away with incentives to reduce preventable hospital readmissions. And it would stop plans to raise payments to primary care doctors and end provisions to increase premiums paid by higher-income beneficiaries, the study said.

Some conservative organizations in Washington see it differently.

Dr. Scott Gottlieb, a physician and fellow with the American Enterprise Institute, said the reform law's changes "turn on misguided faith that efficiency and innovation in medical care can arise through government fiat rather than market competition...These schemes are already degrading the practice of medicine in America."

Analysts at the Heritage Foundation predict cuts in payments to Medicare Advantage plans will force more than 7 million seniors now enrolled in the plans to return to conventional Medicare coverage, while losing extra benefits worth an average of $3,700 a year.

Q. During an interview with The Columbus (Ohio) Dispatch newspaper earlier this month, Romney said people with pre-existing conditions would be covered under his plan even after he does away with Obamacare.

According to the newspaper, he did not explain why insurance companies would agree to cover the very patients they were notorious for dropping for financial reasons, and whose treatment by those companies became a major rationale for the reform effort.

Would insurance companies agree to cover patients with pre-existing conditions without the incentives, and the mandate for millions of uninsured people to get coverage, that the Affordable Care Act provides?

A. Probably not, says John Holahan, director of the Health Policy Center at The Urban Institute, a left-leaning Washington think tank.

Maintaining coverage for "pre-existing conditions is much harder because insurance companies basically agreed to that with the knowledge that there would be a mandate in place and they'd have broad risk pools," Holahan said.

Holahan said by requiring most people to have insurance, companies providing coverage will be able to balance out the sick with greater numbers of people who are generally healthy and won't need much care.

Without those broad-based pools "it's really hard to do. The insurance companies would oppose that, and would win, would be my guess,'' Holahan said.

America's Health Insurance Plans, the health insurance industry's trade association, notes that in several states that have required "guaranteed issue" of insurance, premiums have gone up substantially while choice in coverage has declined.

It recently pointed to several studies from different experts across the political spectrum that all conclude trying to keep the insurance reforms without a requirement to buy coverage would boost

the ranks of the uninsured by an additional 8 million to 24 million, while driving up private health premiums between 10 percent and 40 percent.

Q. In the same interview, Romney said people without insurance still receive health care -- in emergency rooms. "You go to the hospital, you get treated, you get care, and it's paid for, either by charity, the government or by the hospital," he said.

Isn't there a downside to getting primary care at an emergency room, as well as some restrictions on what can be treated?

A. The Emergency Medical Treatment and Active Labor Act, passed by bipartisan majorities and signed into law by Ronald Reagan, has required hospitals to provide health care for serious injuries and women in labor for more than 25 years.

It doesn't mandate treatment for chronic diseases or preventive health care. And the uninsured still get the often-substantial bill for any treatment they receive.

In 2009, Families USA, a Washington-based advocacy group that calls itself "the voice for health care consumers," noted that treating the uninsured cost $116 billion in 2008. Of that, 37 percent was paid out-of-pocket by the uninsured patients, 26 percent was paid by government programs or charities, and 37 percent ($42.7 billion) went unpaid.

Those unpaid services were shifted to insurers, which in turn passed them on as higher premiums for families with insurance. Families USA said the "hidden health tax" for treating the uninsured that year cost an additional $1,017 per family.

Q. America's Health Insurance Plans spent $102.4 million over 15 months lobbying against Obamacare, according to a recent analysis by the National Journal, even though the law requires that tens of millions of currently uninsured people become their new customers. Why?

A. Part of the reason kicked in Aug. 1 when 12.8 million individuals and employers began receiving what will ultimately be $1.1 billion in refunds because insurance companies didn't comply with the Medical Loss Ratio provision of the new law.

That provision requires insurance companies to spend at least 80 percent of premium dollars on health care, instead of administrative costs, marketing and profits. New rules put in place by the U.S. Department of Health and Human Services stipulate -- over the insurance companies' objections -- that sales personnel are a cost on the administrative, not medical, side of the dividing line.

Q. Since it was passed, critics have referred to Obamacare as a "government takeover" of medical care. Is the government now going to be involved in making health care decisions or directly providing services?

A. No. The ACA is not a British-style National Health Service or universal single-payer, Medicare-for-all plan.

The Urban Institute's Health Policy Center released a report this month that says the law "relies primarily on the private market to achieve coverage expansion, using public regulation to make the market work."

Under the ACA, "the vast majority of Americans younger than Medicare age will enroll in privately operated insurance plans and will receive care from private physicians and hospitals."

Critics maintain the individual mandate to have insurance coverage is a government-imposed usurpation that infringes on the right to remain uninsured. The Supreme Court ruled that the penalty for not having insurance falls within Congress' authority to tax.

(Reach Scripps Howard News Service Washington correspondent Bartholomew Sullivan at sullivanb@shns.com.)

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