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  • 1. BMJ 2012;345:e7007 doi: 10.1136/bmj.e7007 (Published 16 October 2012) Page 1 of 2Feature FEATUREUS ELECTIONFact and fiction in the US election healthcare debateVarious claims about the effects of Democrat and Republican health policies have been made inthe run-up to next month’s elections. Michael McCarthy examines their validityMichael McCarthy editorLocalHealthGuide.com, Seattle, Washington, USAThroughout this year’s US presidential campaign, incumbent sound, extending the solvency of the financially troubledPresident Barack Obama and his Republican challenger, former program by eight years, to 2024. Some of those savings do, inMassachusetts governor Mitt Romney, have traded charges and fact, go to help pay for the expansion of insurance coverage forcountercharges about their health policies that often stretch the the uninsured under ACA, but this allows the expansion withouttruth and in some cases appear to be flat-out untrue. adding to the federal deficit.In the first presidential debate, for instance, Romney charged The consensus among most independent fact checking watchdogthat Obama has cut $716bn from Medicare to pay for his groups, such as the website PolitiFact (www.politifact.com),healthcare reform law and instituted a plan to create a “board FactCheck.org, and the Washington Post’s fact checker blogthat can tell people ultimately what treatments they’re going to (www.washingtonpost.com/blogs/fact-checker) is that thereceive.”[1] Republican claim is false.For his part, Obama warned that if Romney were allowed toimplement his policies, more than 50 million Americans would Claim: If ACA is repealed 50 million peoplelose their health insurance and that his plans for Medicare, the will lose their health insurancefederal health insurance plan for elderly people, “would costthe average senior about $6000 [£3700; €4600] a year.” During the presidential debate, Obama repeated the claim thatThese and similar charges have been repeated in the candidates’ if his health reform bill were repealed “you’re looking at 50stump speeches, by their campaign surrogates, and in the million people losing health insurance.” This figure is based onthousands of attack advertisements that are saturating the projections that go out 10 years and includes people who do notairwaves in the heavily contested swing states where the 6 have insurance now and would not, therefore, have it to loseNovember election will be decided. What are the facts? should Romney be elected and repeal the law. So this claim has been judged by most observers to be partially true. Still, a recentClaim: Obama is cutting $716bn from study by the non-partisan Commonwealth Fund estimates thatMedicare to finance his health reform law Romney’s proposals would “increase the number of uninsured people by 12 million compared with the baseline (no AffordableRomney has leveled this claim repeatedly on the campaign trail, Care Act), leaving 72 million people uninsured in 2022.”[4] Ifand his vice presidential running mate, Paul Ryan, repeated the implemented, on the other hand, the study concluded the ACAcharge in his television debate last week with Vice President will reduce the number of uninsured people by an estimatedJoe Biden.[2] 32.9 million, leaving 27.1 million people uninsured by 2022.The claim refers to provisions of the 2010 health reform law,the Patient Protection and Affordable Care Act (ACA), that Claim: Romney will “voucherize” Medicarereduces Medicare spending over 10 years by $716bn, accordingto the most recent estimate by the Congressional Budget Office, Currently, Medicare is a “defined benefit” program, whichwhich provides independent assessments of the budgetary effects means it guarantees that the government will pay for all coveredof legislation.[3] medical services. Romney has proposed converting Medicare into a “defined contribution” plan in which seniors would beDemocrats assert, however, that the savings come primarily given “premium support,” a subsidy that would allow them tofrom reductions in payments to insurers and hospitals and will purchase their own insurance on the private market. Accordinghave no effect on benefits. They say that slowing the growth of to the proposal, the subsidy would be enough to cover the secondMedicare spending actually makes the program more financiallymxmc@mac.comFor personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
  • 2. BMJ 2012;345:e7007 doi: 10.1136/bmj.e7007 (Published 16 October 2012) Page 2 of 2 FEATUREleast expensive plan available. Supporters of the proposal argue spending cuts if costs rise beyond a target growth rate and ifthat giving seniors a choice of more and less expensive plans Congress fails to act to address the increase. But the power ofwill create a competitive market that will drive insurers to lower the board is limited, and by law it cannot ration care, restrictcosts and improve quality. The term “voucherize” is unpopular benefits, shift costs to beneficiaries, alter eligibility, or limitwith seniors—and used freely by the Democrats to attack the treatments doctors prescribe.[5] The fact checking organizationsplan—but most observers say the label is accurate. agree that the claim is untrue.Claim: Romney’s Medicare voucher Competing interests: The author has completed the ICMJE unified disclosure form at www.icmje.org/coi_disclosure.pdf (available onprogram would cost the average senior request from the corresponding author) and declares no support from$6000 a year any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work inThis is a claim the Democrats have made repeatedly, arguing the previous three years; and no other relationships or activities thatthat because the premium support payments would not keep up could appear to have influenced the submitted work.with medical inflation, seniors would end up paying more andmore out of pocket. The claim, however, is based on an earlier Provenance and peer review: Commissioned; not externally peerversion of the proposal and does not account for a more recent reviewed.revision that sets the size of the subsidy to the price of the 1 2012 presidential debate: President Obama and Mitt Romney’s remarks in Denver onsecond cheapest private plan available. If this is the case, Oct. 3. www.washingtonpost.com/politics/decision2012/2012-presidential-debate-president-supporters argue, the subsidy would always cover some form obama-and-mitt-romneys-remarks-in-denver-on-oct-3-running-transcript/2012/10/03/of basic health plan. Although the Democratic claim is based 2 24d6eb6e-0d91-11e2-bd1a-b868e65d57eb_story.html. 2012 vice-presidential debate: Vice President Biden and Rep. Paul Ryan’s remarks inon an older proposal, the lack of specifics in the Republican’s Danville, Ky, on Oct.11. www.washingtonpost.com/politics/decision2012/2012-vice-new proposal has prompted some fact checking organizations, presidential-debate-vice-president-biden-and-rep-paul-ryans-remarks-in-danville-ky-on- oct11-running-transcript/2012/10/11/a5167f1e-13cd-11e2-ba83-a7a396e6b2a7_story.such as PolitiFact, to rate this claim “half-true.” html. 3 Elmendorf DW. Letter to John Boehner, Speaker of the House, US House of Representatives, 24 July 2012. http://cbo.gov/sites/default/files/cbofiles/attachments/Claim: Obama’s health reform law 43471-hr6079.pdf. 4 Health care in the 2012 presidential election: how the Obama and Romney plans stackincludes provisions to implement up. 2012. www.commonwealthfund.org/Publications/Fund-Reports/2012/Oct/Health-Care- in-the-2012-Presidential-Election.aspx?page=2.rationing that will deny care to Medicare 5 Independent Payment Advisory Board. A new approach to controlling Medicare spending. Kaiser Family Foundation, 2011. www.kff.org/medicare/upload/8150.pdf.patientsThis is often called the “death panel” claim and refers to the Cite this as: BMJ 2012;345:e7007Independent Payment Advisory Board, an expert panel created © BMJ Publishing Group Ltd 2012by the ACA that will have the authority to institute MedicareFor personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe