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Feature US Election

Fact and fiction in the US election healthcare debate

BMJ 2012; 345 doi: (Published 16 October 2012) Cite this as: BMJ 2012;345:e7007
  1. Michael McCarthy, editor
  1., Seattle, Washington, USA
  1. mxmc{at}

Various claims about the effects of Democrat and Republican health policies have been made in the run-up to next month’s elections. Michael McCarthy examines their validity

Throughout this year’s US presidential campaign, incumbent President Barack Obama and his Republican challenger, former Massachusetts governor Mitt Romney, have traded charges and countercharges about their health policies that often stretch the truth and in some cases appear to be flat-out untrue.

In the first presidential debate, for instance, Romney charged that Obama has cut $716bn from Medicare to pay for his healthcare reform law and instituted a plan to create a “board that can tell people ultimately what treatments they’re going to receive.”[1]

For his part, Obama warned that if Romney were allowed to implement his policies, more than 50 million Americans would lose their health insurance and that his plans for Medicare, the federal health insurance plan for elderly people, “would cost the average senior about $6000 [£3700; €4600] a year.”

These and similar charges have been repeated in the candidates’ stump speeches, by their campaign surrogates, and in the thousands of attack advertisements that are saturating the airwaves in the heavily contested swing states where the 6 November election will be decided. What are the facts?

Claim: Obama is cutting $716bn from Medicare to finance his health reform law

Romney has leveled this claim repeatedly on the campaign trail, and his vice presidential running mate, Paul Ryan, repeated the charge in his television debate last week with Vice President Joe Biden.[2]

The claim refers to provisions of the 2010 health reform law, the Patient Protection and Affordable Care Act (ACA), that reduces Medicare spending over 10 years by $716bn, according to the most recent estimate by the Congressional Budget Office, which provides independent assessments of the budgetary effects of legislation.[3]

Democrats assert, however, that the savings come primarily from reductions in payments to insurers and hospitals and will have no effect on benefits. They say that slowing the growth of Medicare spending actually makes the program more financially sound, extending the solvency of the financially troubled program by eight years, to 2024. Some of those savings do, in fact, go to help pay for the expansion of insurance coverage for the uninsured under ACA, but this allows the expansion without adding to the federal deficit.

The consensus among most independent fact checking watchdog groups, such as the website PolitiFact (,, and the Washington Post’s fact checker blog ( is that the Republican claim is false.

Claim: If ACA is repealed 50 million people will lose their health insurance

During the presidential debate, Obama repeated the claim that if his health reform bill were repealed “you’re looking at 50 million people losing health insurance.” This figure is based on projections that go out 10 years and includes people who do not have insurance now and would not, therefore, have it to lose should Romney be elected and repeal the law. So this claim has been judged by most observers to be partially true. Still, a recent study by the non-partisan Commonwealth Fund estimates that Romney’s proposals would “increase the number of uninsured people by 12 million compared with the baseline (no Affordable Care Act), leaving 72 million people uninsured in 2022.”[4] If implemented, on the other hand, the study concluded the ACA will reduce the number of uninsured people by an estimated 32.9 million, leaving 27.1 million people uninsured by 2022.

Claim: Romney will “voucherize” Medicare

Currently, Medicare is a “defined benefit” program, which means it guarantees that the government will pay for all covered medical services. Romney has proposed converting Medicare into a “defined contribution” plan in which seniors would be given “premium support,” a subsidy that would allow them to purchase their own insurance on the private market. According to the proposal, the subsidy would be enough to cover the second least expensive plan available. Supporters of the proposal argue that giving seniors a choice of more and less expensive plans will create a competitive market that will drive insurers to lower costs and improve quality. The term “voucherize” is unpopular with seniors—and used freely by the Democrats to attack the plan—but most observers say the label is accurate.

Claim: Romney’s Medicare voucher program would cost the average senior $6000 a year

This is a claim the Democrats have made repeatedly, arguing that because the premium support payments would not keep up with medical inflation, seniors would end up paying more and more out of pocket. The claim, however, is based on an earlier version of the proposal and does not account for a more recent revision that sets the size of the subsidy to the price of the second cheapest private plan available. If this is the case, supporters argue, the subsidy would always cover some form of basic health plan. Although the Democratic claim is based on an older proposal, the lack of specifics in the Republican’s new proposal has prompted some fact checking organizations, such as PolitiFact, to rate this claim “half-true.”

Claim: Obama’s health reform law includes provisions to implement rationing that will deny care to Medicare patients

This is often called the “death panel” claim and refers to the Independent Payment Advisory Board, an expert panel created by the ACA that will have the authority to institute Medicare spending cuts if costs rise beyond a target growth rate and if Congress fails to act to address the increase. But the power of the board is limited, and by law it cannot ration care, restrict benefits, shift costs to beneficiaries, alter eligibility, or limit treatments doctors prescribe.[5] The fact checking organizations agree that the claim is untrue.


Cite this as: BMJ 2012;345:e7007


  • Competing interests: The author has completed the ICMJE unified disclosure form at (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.