If Mitt Romney wins the presidential election, this much is certain: He will do everything he can to make good on his vow to repeal the Affordable Care Act, President Obama’s 2010 health care overhaul. However, his ability to follow through on this promise depends on more than just winning the presidential election.

There are several “what ifs” that would need to fall into place to bring about substantial changes to Medicare and the Affordable Care Act (ACA) in a Romney presidency; and chief among them is the shape of Congress after next Tuesday’s election.

A Romney win without a Republican majority in Congress will allow the ACA and the law’s numerous Medicare provisions to cautiously unfold and for the debate to continue on the best way to reform the entire Medicare program.

A Romney presidency with a GOP majority, however, would give him the political power to completely overturn, as pledged, the ACA, which is often referred to as “Obamacare.” It would also allow Romney to push through Congress his (and Rep. Paul Ryan’s) version of a Medicare program that would interact more with the private sector in the management of benefits.

Health care policy experts have been weighing in on what a Romney win could mean for Medicare ever since he chose Ryan as his running mate, who is the architect of a House budget plan that includes a structural overhaul of Medicare.

Romney and Medicare Without a Congressional Majority

One of the biggest questions is what authority Romney would have as president to change components of the ACA and to fundamentally change the way Medicare is administered if there is no Republican majority in Congress. Because the ACA was legislation proposed in and approved by Congress and President Obama, most changes would have to take place through the legislative process, analysts say.

Analysts also say that Romney, as president, would be responsible for implementing the ACA. However, he could choose to modify various components through regulation. 

While he couldn’t single-handedly alter the “broad outline” of the ACA, a Romney administration “could make the essential benefits package less comprehensive,” according to Paul Van de Water, senior fellow at the Center on Budget and Policy Priorities, a self-described nonpartisan research and policy institute.

Still, “as long as the law is there with legislative deadlines, presumably, Romney won’t want to do things that are against the law,” said Leighton Ku, a professor in the Department of Health Policy and the director of the Center for Health Policy Research at The George Washington University School of Public Health and Health Services. “At a certain point, he would risk becoming an outlaw.” 

Additionally, the ability of Congress to take substantial action will rely on retaining the current balance of power, particularly in the Senate. Right now, Republicans control the House and the Democrats have a narrow Senate majority.

All 435 seats in the House are up for election, with 218 seats needed for a political majority. Currently, there are 240 Republicans and 190 Democrats in the House, with five vacancies. A New York Times analysis estimates there are 228 solid or right-leaning seats for Republicans, and 183 solid or left-leaning seats for the Democrats, which leaves 24 seats as toss-ups in the race for the House. 

The current Senate is comprised of 51 Democrats, 2 Independents and 47 Republicans, and 33 seats are up for election. It should be noted that more than 50 votes are needed for a majority rule, with the vice president casting a vote in the case of a tiebreaker. The New York Times analysis estimates 42 seats are solid for the Republicans and that the Democrats can count on 40 continuing seats. This last number includes the seats of the two Independents, who caucus with the Democrats and are up for election in 2012. Eight Senate seats are in the toss-up category.

Overturning the ACA

To be sure, a Romney win with a GOP majority in Congress could bring the ACA implementation to an abrupt halt. And if Romney does not put forth an ACA alternative, health care reform will essentially be dead, as Congressional Republicans have vowed to repeal it.

“Romney can’t introduce a bill to Congress, so he’ll have to find someone—and it won’t be too hard—to introduce a bill saying ‘the Affordable Care Act is hereby repealed,’” said Richard Kaplan, professor of law at the University of Illinois.

However, legislators aren’t just going to roll over and take it, Kaplan added. “They’ll want their perspectives included. It is highly unlikely that Romney will be able to repeal all of Obamacare.”

Romney has said that he would keep some of the ACA's reforms, such as provisions to allow young adults to stay on their family’s insurance plan and a ban on insurance companies from excluding patients with pre-existing conditions.

The ACA is on track to guarantee health care coverage to nearly all Americans starting in 2014. The law also seeks to cut health care costs, which are projected to eat up 20 percent of federal revenues by 2022.

Romney has argued that Obamacare is too costly and that more substantive changes in Medicare are needed. He’s also made it clear that he believes it should be up to the states, not the federal government, how to administer health coverage.

“If Romney could muster a 50-vote majority in the Senate, and retain control of the House, then they could use the reconciliation process to repeal most of the significant aspects of health reform, particularly the coverage expansion,” Van de Water said.

As governor of Massachusetts, he supported guaranteed health coverage, with federal aid. Massachusetts had a relatively low rate of uninsured citizens, though, so this, among other factors, made it easier to expand coverage than it would in most states, added Van de Water.

The 50 million uninsured people in the United States are understandably anxious about what a Romney presidency could mean for health care coverage. Romney has suggested that uninsured people do indeed have health care in the form of hospital emergency rooms, but that doesn’t address those with chronic conditions or the need for preventative medicine. This also doesn’t take into account that emergency room care costs the health care system exponentially more than care that is provided earlier in the course of an illness.

“The conclusion is that Romney and his Republican colleagues don’t have a plan that will lead to anything near universal coverage,” Van de Water said. Romney has spoken of ideas to make it easier for insurance companies to sell products in states that further expand the coverage of the high-risk pool, but those “haven’t been shown to provide marginal reductions in the number of uninsured.”

Premium Support as the Cornerstone of Medicare Reform

The Romney campaign has stated that it will not preserve the ACA’s cuts to Medicare.

“Mitt Romney and Paul Ryan have always been fully committed to repealing Obamacare, ending President Obama’s $716 billion raid on Medicare, and tackling the serious fiscal challenges our country faces,” said Romney policy director Lanhee Chen last August, within days of Ryan’s vice presidential nomination to the GOP ticket.

A Romney administration would seek to replace the Medicare ACA reductions with a different set of reforms. The Romney–Ryan market-driven Medicare reform plan seeks to overhaul the program by granting premium supports to new recipients to buy private health insurance, starting in 2022. Seniors who choose a more expensive plan than the credit is worth would have to make up the difference—but the plan does offer higher allowances for lower-income beneficiaries and those in poorer health.

“The plan to ‘voucherize’ Medicare would represent the most significant change to Medicare since the program began,” Kaplan said, adding that it would require Congressional approval.

Those turning age 65 before 2022 would be eligible for most of Medicare in its current form, but wellness visits and some cancer screenings would no longer be free if he is successful in repealing those aspects of ACA.

Their plan also allows the selection of Traditional Medicare as an option for those who opt out of premium support, but if Traditional Medicare costs more, then beneficiaries would be on the hook for the difference.

In addition, there would be a difference between how the ACA and a Romney plan would address the so-called “donut hole.” The donut hole is a coverage gap in the Medicare Prescription Drug Plan (Part D), whereby once drug costs exceed a certain amount, Medicare recipients must pay out of pocket until a higher level kicks in. The ACA closes the gap by 2020, while Romney’s plan would leave it open.

Romney would also seek to increase the Medicare eligibility age from 65 to 67. Starting in 2023, Romney’s proposal calls for increasing the age two months each year until it reaches age 67 in 2034.

Proponents of raising the Medicare eligibility age argue that people are living longer than when Medicare was first passed and that delaying the benefits for those at the younger end of the Medicare population would preserve the program for future beneficiaries. 

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