Since 2010, the Republican Party has united under one goal: “Repeal and replace ‘Obamacare’.” It comes as no surprise then, that the 2012 Republican presidential candidates have pledged that no matter who wins the nomination, if a Republican is elected to office, the Patient Protection and Affordable Care Act (PPACA) will be repealed.

If the law is rescinded, however, do the candidates share the same unity on how—or whether—it should be replaced? Although history has shown that campaign promises should generally be taken with a grain of salt, it seems as though the answer is yes. An examination of the health policy proposals put forth by former Massachusetts governor Mitt Romney, Texas Rep. Ron Paul, and former Georgia Representative and Speaker of the U.S. House of Representatives Newt Gingrich finds only minute differences in their positions on health care.

The Romney route
During the 2012 Republican presidential primary season, many conservatives have criticized Mr. Romney for his 2006 Massachusetts healthcare plan. The plan, which requires nearly every citizen to purchase health insurance or pay a fine, is said to have served as a model for the authors of PPACA.

During a Republican debate in Iowa in August 2011, Mr. Romney told voters, “We put together a plan that was right for Massachusetts. The president took the power of the people and the states away from them.” According to his campaign website, if elected, Mr. Romney would issue a waiver to all 50 states from PPACA. He also pledges to work with Congress to repeal the legislation “as quickly as possible.”

Nevertheless, Mr. Romney does support several individual components of PPACA, including ensuring that individuals with pre-existing conditions cannot be denied coverage and implementing electronic medical records.

State flexibility—Once PPACA is repealed, Mr. Romney would implement policies to restore the responsibility to care for their citizens to the states. According to his campaign website, he would foster flexibility by encouraging states to experiment using exchanges, high-risk pools, and risk adjustment to discover how to best care for their poor, uninsured, and chronically ill residents. He would also use block-grants for Medicaid, providing states with lump sums of money with few restrictions on how it should be spent, to allow states to shape healthcare programs to meet their individual needs.

Reducing uninsured numbers and healthcare spending—Rather than impose an individual mandate, Mr. Romney would encourage universal health insurance coverage by offering a tax deduction to those who buy their own health insurance. As a further incentive, he would make health insurance more affordable by fostering its purchase across state lines and empowering individuals and small businesses to form purchasing pools to negotiate for lower prices.

Mr. Romney believes that increasing individual responsibility for healthcare bills is one way to reduce individual healthcare spending. Therefore, he supports co-insurance plans, which require patients to pay a percentage of their healthcare bill after meeting their deductible. To help families pay for their bills, he would remove current barriers to participation in tax-exempt Health Savings Accounts (HSAs). According to Mr. Romney, having a stake in one’s own health care will increase patient awareness and force individuals to become more cost-conscious about their healthcare decisions.

Medical liability reform—Throughout his career, Mr. Romney has been a strong proponent of medical liability reform. While governor of Massachusetts, he issued a proposal to place a $500,000 cap on noneconomic damages and reduce lawyer fees for verdicts higher than $500,000. On his campaign website he states, “The current medical liability system encourages defensive medicine and drives up healthcare costs. Preventing excessive damage awards…could protect litigants with legitimate grievances while preventing spurious litigation.”

Mr. Romney also supports offering innovation grants to states to pursue policies such as healthcare courts and forms of alternative dispute resolution, or the settling of disputes outside of the judicial process.

Medicare—To preserve Medicare, Mr. Romney would establish a premium support model that enables seniors to purchase an insurance plan that meets their needs using a government subsidy. Under this plan, seniors would be able to choose from private insurance plans and a traditional fee-for-service Medicare option. Mr. Romney has publicly supported a similar plan introduced by Rep. Paul Ryan (R-Wisc.) and Sen. Ron Wyden (D-Ore.) that would offer seniors an allowance enabling them to choose from a variety of healthcare plans including a traditional fee-for-service Medicare plan. (See “Will Medicare Work in a Private Sector World?”).

According to Mr. Romney’s campaign website, however, if the traditional Medicare option becomes too costly to provide, premiums for that plan will be raised. He also wants to publish an annual federal balance sheet “to help people understand the impact of entitlement spending on the budget and economy.”

Rep. Ron Paul, MD
Before entering public service, Rep. Paul was a practicing obstetrician-gynecologist. According to his campaign website, this experience allowed him to witness the negative impact on the physician–patient relationship of the growth of corporations and excessive regulation of the U.S. healthcare system.

Consumer-driven health care—Rep. Paul believes that the current healthcare system promotes dependence on the federal government. To “wean” Americans from government programs, he would remove barriers to obtaining HSAs and would enact reforms to make health care more affordable.

To drive down costs, Rep. Paul would allow the sale of health insurance across state lines and would mitigate the cost of defensive medicine by providing a tax credit to individuals who purchase “negative outcomes” insurance before medical treatment. Unlike his opponents, Rep. Paul does not favor federal medical liability reform and has voted against legislation to place federal caps on damages. Instead, he would defer to states to enact their own medical liability reforms.

Medicare and Medicaid—Although Rep. Paul believes that lowering healthcare costs would reduce Americans’ dependency on the federal government, he would not dismantle existing entitlement programs. According to his campaign website, he would honor the commitment made to America’s seniors by preserving the Medicare program, but would encourage healthcare independence for younger Americans through HSAs.

Rep. Paul would also keep the Medicaid program, but would alter it by offering block grants to states, giving states the flexibility to “solve their own unique problems without harming those currently relying on the program.”

Newt Gingrich
Former House speaker Newt Gingrich is perhaps the most progressive of the three candidates when it comes to healthcare reform and has supported many policies that are central to PPACA. In his 2007 book, Real Change, Mr. Gingrich advocated for a “21st Century intelligent health” structure to reduce waste, increase transparency, and provide timely healthcare information to patients and doctors. This system is similar to the electronic health record and prescribing systems being implemented by President Obama.

Despite his more progressive positions on healthcare, Mr. Gingrich has pledged to repeal PPACA. According to his website, the former House speaker would replace the law with a “Patient Power” healthcare plan that would reform the U.S. healthcare system into a “coordinated and innovative” model that delivers more choices at a lower cost. To drive down health insurance costs, he would allow individuals to purchase insurance across state lines and would encourage the purchase of insurance by offering Americans the choice between a tax credit and “the ability to deduct the value of their health insurance up to a certain amount.”

Medicare—Like the other Republican contenders, Mr. Gingrich would block grant Medicaid to give states the freedom to develop programs to suit the needs of their citizens. He supports the establishment of state ‘high-risk pools,’ or health insurance plans created by states to ensure coverage for chronically ill individuals. He also believes in increasing individual responsibility for healthcare costs and would extend the ability to enroll in HSAs to all Americans, including Medicare and Medicaid beneficiaries.

Mr. Gingrich does not support a mandatory Medicare voucher plan like that proposed by Rep. Ryan. Instead, he would implement a premium support model that would give seniors the option to choose between a private health insurance plan and the traditional Medicare plan.

Medical liability reform—Mr. Gingrich has been a consistent advocate of tort reform to curb medical costs. In 1994, he included the “Common Sense Legal Reform Act,” which would have reformed the tort system by imposing “loser pays” rules and capping punitive damages, as part of his Contract with America. In 2009, during the healthcare reform debate, Mr. Gingrich submitted an op-ed in the Washington, D.C., newspaper Politico stating, “The fundamental driving force behind any national health reform proposal is improving care and reducing costs, tort reform should be contained in every rational approach to health reform.”

Madeleine Lovette is the communications specialist in the AAOS office of government relations; she can be reached at lovette@aaos.org