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When it comes to health care, the choice between the two presidential candidates could not be more stark. The Affordable Care Act, passed in 2010, is President Obama's signature legislative achievement, and also one that Republican challenger Mitt Romney has vowed to repeal. As part of our series Solve This, NPR's Julie Rovner looks at how each candidate would address the problem of health care.
JULIE ROVNER, BYLINE: In 2010, Democrats in tough races shied away from touting the just-passed health law, then known by its detractors as Obamacare. But now the president has embraced both the name and the law on the campaign trail. Here he was last week in New Hampshire.
PRESIDENT BARACK OBAMA: And so we passed health reform - yes, I like the name Obamacare - so your insurance companies can't jerk you around anymore.
ROVNER: Touting specifics too, at least the popular ones.
OBAMA: So young people can stay on their parent's plans till they're 26. So women can't be charged more than men for their insurance. Being a woman's not a preexisting condition.
ROVNER: The health law, however, has been one thing on which Mitt Romney has been pretty consistent. Here he is just following the Supreme Court's decision in June that found the law largely constitutional.
MITT ROMNEY: What the court did not do on its last day in session I will do on my first day if elected president of the United States. And that is I will act to repeal Obamacare.
ROVNER: Now, Romney can't actually repeal the law on his first day in office. He'll need Congress to do that. And it might take a while. But the big question is what, if anything, he'd try to replace the law with. Here's how he answered that question at the first presidential debate in Denver.
(SOUNDBITE OF DEBATE)
ROMNEY: It's a lengthy description, but number one, pre-existing conditions are covered under my plan. Number two, young people are able to stay on their family plan. That's already offered in the private marketplace. You don't have to have the government mandate that for that to occur.
ROVNER: In fact, Romney's staff had to step in after the debate to clarify that, no, pre-existing conditions wouldn't be covered for most people, only those who have maintained continuous coverage. And there wouldn't be any guarantee for young adults to stay on their parents' plans. Romney says it would happen because the private sector's already doing it, albeit with a push from the law. Romney says he believes in the power of the private sector for most things when it comes to health care.
(SOUNDBITE OF DEBATE)
ROMNEY: But the right answer is not to have the federal government take over health care and start mandating to the providers across America, telling a patient and a doctor what kind of treatment they can have. That's the wrong way to go. The private market and individual responsibility always work best.
ROVNER: Now, this sounds curious to people like Jonathan Gruber. He's an economist from M.I.T. who worked on both the Massachusetts plan that passed when Romney was governor in 2006 and the federal law passed two years ago. Gruber says he's stunned at how Romney can still profess support for his state's law but opposition to the federal law, since the two are such close cousins.
JONATHAN GRUBER: This is an unprecedented case of a major national policy where we run an experiment first.
ROVNER: And that experiment has worked well in Massachusetts, says Gruber, where the rate of uninsured has fallen.
GRUBER: Down to three percent, compared to an 18 percent national rate. And we wanted to fix what was a broken non-group insurance market. And we did. We've lowered premiums in that market by 50 percent.
ROVNER: What the original Massachusetts law did not do, however, is attempt to lower health costs overall. And that's what makes the federal law so controversial. Gruber says there are two big barriers to getting a handle on health spending.
GRUBER: The first is the science, which is we don't really know how to do it. The second is the politics, which is even if we did, the politicians wouldn't let us.
ROVNER: That said, however, the Affordable Care Act does start to take some steps in the direction of cost control. The problem, says Len Nichols of George Mason University, is that most of them are still largely invisible to the public.
LEN NICHOLS: It's all technical. It's all professional. It's all behind the scenes.
ROVNER: Nichols says that includes things like paying hospitals less if patients who are discharged are readmitted to the hospital too soon or encouraging doctors and hospitals to better coordinate patient care.
NICHOLS: But it is indeed making health care cheaper. Why are health care premiums growing less than they were? Part of the reason is because people have figured out, hey, you know, we can do this stuff cheaper. And we're going to have to survive in the long run. So let's start now.
ROVNER: The question is, does the health care industry need a federal law to make these changes continue? Michael Cannon of the Libertarian Cato Institute says no.
MICHAEL CANNON: All the innovations that Obamacare is trying to impose in a top down sort of way already exist in the marketplace.
ROVNER: He, like Romney, says real cost control can only come from the private sector.
CANNON: At the same time, giving patients the money is going to encourage them to be more cost conscious consumers and force prices down in a way that government has proven itself unable to do.
ROVNER: The problem is, no one knows which would work better because neither has really been tried. So the choice is to let the new law continue to play out, or repeal it and see if Congress can pass something else. That is if it doesn't take Congress another generation to reach another compromise.
Julie Rovner, NPR News, Washington.