Republicans and Democrats agree that the U.S. healthcare system needs reform. The United States spends more on healthcare than any country in the world per capita and as a portion of total GDP (the size of the country’s economy). However, Americans as a whole do not receive the best care, as shown by measures such as life expectancy (where the United States ranks 42nd). Over 15 percent  of American citizens do not have health insurance; yet for those who can afford it, the most advanced treatments can be found in the United States. The debate about healthcare has focused on how to lower costs, improve care, and increase  coverage, without eliminating the option to buy the best care available.

This debate has a turbulent history. A national plan to provide healthinsurance to all American citizens was first supported in a presidential campaign by Theodore Roosevelt in 1912. By the 1950s, the current model of employer-based health insurance became prominent. Since then, several major reforms have been enacted. In 1965 President Lyndon Johnson signed into law Medicare and Medicaid, programs that provide healthcare to the elderly, poor, blind, and disabled. In 1973, Richard Nixon signed the Health Maintenance Organization (HMO) law, funding the creation of group insurance plans (HMOs) meant to prevent illnesses in communities rather than treat them after the fact, when it is more expensive. In 1986, Ronald Reagan signed two new laws, one that required hospitals to treat all emergency room patients in need of immediate care even if they do not have health insurance, and another that allowed people to keep their employer’s  insurance  for 18 months after losing their job. Each of these reforms was the result of vigorous debate, and each required at least some support from both Democrats and Republicans to pass.

When he took office in 2009, President Barack Obama called on Congress to pass comprehensive healthcare reform to solve the problems of cost, quality, and coverage. Most Republicans flat-out rejected plans to increase the role of government in healthcare provision, while more liberal Democrats wanted a single-payer system, which would allow all Americans to buy the same insurance. Mr. Obama proposed instead that the current insurance system should remain, with the addition of a government-run “public option.” This proposal failed, and Obama and Congress ultimately compromised by including an “individual mandate” requiring all those who can afford to buy health insurance to do so. The intent of the mandate was to increase the pool of people in the health insurance system, thereby lowering the overall cost of insurance for everybody and reducing the number of uninsured people relying on free (and expensive) emergency room care. Proponents of the mandate argue that expanding coverage is the best way to reduce the cost because it encourages individuals to seek preventative care earlier, thus saving insurers and patients more on long-term costs. Under the mandate, there is a tax penalty for citizens who can afford insurance but do not buy it. Although no Republicans supported the final bill with the mandate in place, Congress passed the Patient Protection and Affordable Care Act, which became law on March 23, 2010. Some of the law’s provisions have already gone into effect.

Shortly after its passage,  however,  several individuals, states, and lobbying groups, with the support of congressional Republicans, sued the federal government over the law, saying that the individual mandate was unconstitutional because it required all citizens to purchase a good. They argued that because of the Tenth Amendment, which leaves all powers not expressly given to the federal government up to the states and the people, the federal government could not require people to buy insurance. Those believing in the constitutionality of the mandate asserted that insurance is a form of interstate commerce (commerce across state borders) and therefore the mandate to buy insurance is covered by the Commerce Clause of the Constitution, which gives the federal government the right to regulate interstate commerce. The case went to the Supreme Court, which decided on June 28, 2012, that the mandate and the law in its entirety is constitutional. Although the Court agreed that insurance did not count as interstate commerce,  it ruled  that  the  mandate  was  constitutional because it was a tax, similar to the federal taxes required of all citizens who can afford to pay them. Unless Congress chooses to reverse the law, the Affordable Care Act will continue to be implemented, becoming fully effective by 2020.

The election debates surrounding healthcare reform will center mainly on federal insurance mandates, reproductive care, and the future of Medicaid and Medicare. Republicans have advocated for reduced federal power in the healthcare system  and  have  offered  cost-cutting  alternatives  such as capping malpractice damages awards and promoting competition among insurance providers. Both sides generally agree  that  reform  is  necessary,  but  proposals  for  fixing healthcare in America are firmly divided along party lines. Even so, both sides believe that insurers should not be able to deny or cancel coverage to patients based on pre-existing conditions.

Governor Mitt Romney passed a healthcare law in Massachusetts that was similar to the Affordable Care Act when he served as governor, but he has opposed Mr. Obama’s law, saying that he does not support the law’s provisions on a federal level. His plan for national healthcare would be to issue an executive order that paves the way for the federal government to issue “Obamacare” waivers to all fifty states. Then he would work with Congress to repeal the full legislation and pursue policies that give each state the power to craft a healthcare reform plan that is best for its own citizens. As his website states, “the federal government’s role will be to help markets work by creating a level playing field for competition.”

Reproductive healthcare and access to proper healthcare for women has been connected to the health reform issue as well. The Obama administration has supported the inclusion of contraception coverage in reform bills, maintaining that access to reproductive care is a basic right of women and families  as well  as a necessary  component  for reducing overall healthcare expenditures. Governor Romney and the Republicans have pushed for reducing or eliminating federal funding for reproductive care services and organizations such as Planned Parenthood, arguing that taxpayers should not be compelled to fund services against which they have religious or ideological disagreement.

-This article was written by Denise Yu and appears in full in The IDEA Guide to the 2012 U.S. Presidential Elections.