Joyce Beck, who runs a small hospital and network of medical clinics in rural Nebraska, is reluctant to plan for the future until voters decide between President Barack Obama and Mitt Romney. The candidates' sharply divergent proposals for Medicare, Medicaid and coverage of the uninsured have created too much uncertainty, she explained.
"We are all on hold, waiting to see what the election brings," said Beck, chief executive of Thayer County Health Services, based in Hebron.
When Americans go to the polls next month they will cast a vote not just for president but for one of two profoundly different visions for the future of the country's health care system. With an Obama victory Nov. 6, the president's signature health care law – including the contentious requirement that most Americans obtain health insurance or pay a tax penalty – will almost certainly come into full force, becoming the largest expansion of the safety net since Lyndon Johnson pushed through his Great Society programs almost half a century ago.
If Romney wins and Republicans capture the Senate, much of the law could be repealed – or its financing cut back – and the president's goal of achieving near-universal coverage could take a back seat to Romney's top priority, controlling medical costs.
Given the starkness of the choice, historians and policymakers believe this election could be the most significant referendum on a piece of social legislation since 1936, when Republican Alf Landon ran against Franklin D. Roosevelt and his New Deal programs.
Nearly eight decades have passed, but the debate sounds strikingly familiar: Landon described the Social Security Act, passed in 1935, as "the largest tax bill in history" and called for its repeal.
"It is very rare for a political party to pass a social program of this magnitude and then to face the possibility of a rollback or repeal in a presidential election," said James A. Morone, a professor of political science at Brown University who has studied the history of health policy.
For Medicare and Medicaid, the government health programs for older Americans, low-income people and the disabled, the candidates have sharply different visions as well. Romney's proposals call for fundamental changes in the structure of the programs, placing more emphasis on private-sector competition and much less on government regulation.
Obama would expand Medicaid to cover millions more people; Romney would effectively shrink it, giving each state a fixed amount of federal money to cover its disadvantaged population with more control over eligibility and benefits. Romney would eventually give each Medicare beneficiary a fixed amount of federal money to pay premiums for either the traditional Medicare program or private insurance. Obama would preserve the structure of Medicare but try to rein in costs, in part by trimming payments to health care providers.
Passage of the Affordable Care Act in 2010 was, to many, Obama's most significant legislative accomplishment. But the law proved so divisive that undoing it has become a central rallying cry of Republicans seeking to retake the White House.
Julian E. Zelizer, a history and public affairs professor at Princeton, said that Obama "has not embraced his own record with as much enthusiasm, passion and confidence" as either Roosevelt or Johnson did. But the president has, in recent weeks, responded more aggressively to the critics. He has even embraced the derisive term "Obamacare," saying: "I do care. That's why we passed the bill."
Armed with data suggesting that the law is popular with crucial groups of voters – including young people, women and Latinos – Obama plans to run more television commercials and distribute fliers taking credit for popular provisions of the 2010 health law and asserting that Romney would take away Medicare's "guaranteed benefits." As seen in last week's presidential debate, the health care discussion has become a dizzying flurry of numbers, bold claims and counterclaims.
Obama and Democrats in Congress have beaten back efforts to change the law before its major provisions take effect. But after the election, Congress will be under intense pressure to rein in deficits and debt, and lawmakers will focus anew on the costs of Medicare, Medicaid and the new health care law, which together are expected to account for one-third of all federal spending in 2022.
Paul B. Ginsburg, president of the nonpartisan Center for Studying Health System Change, said that a willingness to compromise might help Obama persuade Republicans to accept the health care law if he wins a second term.
For example, Ginsburg said, the president and congressional Democrats might agree to delay the biggest, most expensive parts of the law for a year, giving the administration and states more time to prepare and saving a substantial amount of money. He also suggested that to help with deficit reduction, Obama and Congress might reduce the size of the federal subsidies meant to help middle- income people buy insurance.
Whether Obama's law will slow the overall growth of health care costs remains to be seen.