The Health Care Question: After the November Election, What Happens Next?

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The outcome of the November 6, 2012 presidential election will mean big changes for all health care consumers -- including people living with HIV/AIDS -- no matter who wins the White House. A comparison of the candidates' positions on health care follows.


Governor Mitt Romney, the Republican nominee, has pledged to issue an executive order on his first day in office to halt any further implementation of the Patient Protection and Affordable Care Act's (ACA) sweeping health care policy reforms and seek a full repeal of the law. Despite leading efforts as governor of Massachusetts to adopt a similar set of measures that inspired the ACA (see "RomneyCare and HIV/AIDS" in this issue), Romney says the prescription for the uninsured should be decided by each state and not the federal government.

Pre-existing conditions: Romney's plan would ensure coverage for individuals with pre-existing conditions who maintain continuous coverage. His plan does not include routes to credible coverage for uninsured individuals with pre-existing conditions. In a CBS News' 60 Minutes interview that aired on September 23, Romney pointed to emergency rooms as a form of health care for people without insurance.

Private insurance reform: Romney supports legislation to offer tax breaks to purchasers of individual health insurance coverage so they receive the same tax breaks as individuals with employer-based group insurance. Romney also advocates multi-state insurance products to help control the cost of insurance premiums. Other reforms, such as provisions to allow children to remain on their parents' plans into early adulthood, would be left to the states to decide.

Medicaid: Romney supports block grants for states to implement Medicaid, the federal and state health insurance programs for the poor, disabled, and elderly. Growth in the federal Medicaid grants would be capped at the rate of inflation plus 1%. While the per capita growth in spending is 2.1% lower in Medicaid than in private plans, Medicaid growth has remained higher than inflation. With an aging Baby Boomer generation, long-term care and other care needs in Medicaid are likely to raise Medicaid spending even higher.

Medicare: Romney's repeal of the ACA would restore the large "donut hole" in Medicare prescription drug coverage and his campaign has yet to announce how, or if, it would address this added cost to Medicare beneficiaries.

His Medicare plan would convert the program to a voucher system, providing beneficiaries with a fixed dollar amount to purchase private coverage. The proposal would not affect current retirees or those nearing retirement but be established for future retirees.


President Obama, the Democratic nominee seeking a second term, ushered passage of the federal health reform law in 2010. The law's most significant provisions go into effect in January 2014. Sustaining implementation of the ACA is at the core of his second-term agenda.

In a twist of political irony, the ACA is loosely modeled on a health care plan in Massachusetts enacted by then-Governor Romney. This fact notwithstanding, candidate Romney supports the Massachusetts plan but disavows the ACA and pledges to repeal it if elected president (see above). How the Massachusetts plan impacts its HIV-positive residents is one way to assess the potential impact of the ACA on the nation's ongoing AIDS fight (see "RomneyCare and HIV/AIDS" in this issue).

Pre-existing conditions: Under the ACA, the cost of private insurance premiums will be based solely on the individual's age, geographic location, and tobacco use. Exclusions for pre-existing conditions will be outlawed beginning in 2014.

The Pre-Existing Condition Insurance Plan (PCIP) is a program created by the Affordable Care Act to help provide coverage for uninsured people with pre-existing conditions until new insurance market rules go into effect in 2014. The PCIP, which is administered by either individual states or the U.S. Department of Health and Human Services, will provide health insurance coverage for U.S. citizens or legal residents who have been uninsured for at least six months, have a pre-existing condition, or have been denied health coverage because of their health condition. There are no income thresholds required for pre-existing condition coverage and premium rates, as well as deductibles, vary in each state.

Private insurance reform: Also in 2014, every state will have a "health insurance exchange," which is an online marketplace that allows individuals and small businesses to compare and purchase health insurance plans. Either the state government or the federal government will run the exchange in each state.

The hotly contested "individual mandate" requiring Americans to carry health insurance coverage was recently upheld by the U.S. Supreme Court. People and small businesses who fail to comply with the requirement will be assessed a federal tax penalty.

The exchange will help U.S. citizens and some legal residents with annual incomes above $11,170 (or $23,050 for a family of four)* to shop for and purchase private health insurance. Eligible individuals with incomes up to $44,680 (or $92,200 for a family of four) will be provided a federal subsidy to help offset the cost of mandated insurance coverage.

Out-of-pocket health care costs are capped by the ACA to prevent health care-related bankruptcies that all too often occur after an injury or catastrophic illness. Other ACA reforms include guaranteed coverage without co-pays for preventative health care, including HIV testing and contraception for women, a provision that went into effect recently.

"The ACA is a lightning rod issue for many voters, both for and against. How might the law help people with and at risk of HIV?"

Medicaid: The Supreme Court affirmed the constitutionality of the ACA and kept virtually all its provisions intact. While upholding the Medicaid expansion, a central provision to cover low-income citizens, the Supreme Court ruled that the federal government could not withhold all of a state's Medicaid funding in order to enforce the expansion provision, as was previously stated in the law. The Court ruled that only new funding available for the expansion can be withheld as a penalty for failure to expand Medicaid eligibility. Facing a less severe penalty, 15 states have already announced intentions to not expand Medicaid as required by the ACA and 22 more are undecided.

States that elect the expansion will receive federal funds to offset 100% of their new costs in 2014-2016, dropping to 90% by 2020. The law will make Medicaid an insurance program for low-income Americans with incomes up to $15,420 ($31,812 for a family of four), regardless of health status. Medicaid provider payment rates will also rise to match Medicare rates for a two-year period beginning in 2013, which should expand the number of medical providers willing to accept Medicaid coverage.

Medicare: Under the ACA, the so-called "donut hole" in Medicare prescription drug coverage shrinks over time. As a source of revenue to pay for its many new provisions, the ACA reduces incentives to health insurance companies to offer Medicare Advantage plans. The reduced incentives are not expected to affect Medicare benefits.

The ACA is a lightning rod issue for many voters, both for and against. How might the law help people with and at risk of HIV, if fully implemented? Are we better off halting implementation and starting over with Romney's plans for the nation? The answers to these questions are critical for everyone committed to the fight against HIV/AIDS as we head to the polls in November.

* Income eligibility amounts cited reflect current threshold amounts published in the 2012 HHS Poverty Guidelines_. The Census Bureau updates poverty threshold amounts annually._

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