New York Times – Editorial.

The outcome of the presidential election will determine which of two opposing paths the nation will follow on health care for all Americans. If voters re-elect President Obama, he will protect the health care reforms that are his signature domestic achievement. If they elect Mitt Romney, they will be choosing a man who has pledged to repeal the reform law and replace it with — who knows what?

The competing visions are often difficult to evaluate because the Republican candidates — Mr. Romney and his running mate, Paul Ryan — have become so artful about obfuscating their plans for Medicare, Medicaid and what they will do to reform the whole system. Almost nothing the Republican candidates say on these or other health care issues can be taken at face value.

Here are some of their bigger evasions:

REPLACING OBAMACARE Although Mr. Romney has said he wants to “repeal and replace” the Affordable Care Act, he has provided few details on what he would replace it with. When challenged to do so at the first presidential debate, Mr. Romney never quite answered and made some egregious misstatements along the way, some of which were repeated by Mr. Ryan in the vice-presidential debate.

Mr. Romney asserted that his plans had already been laid out in “a lengthy description,” implying that anyone could read the whole story by turning to his campaign Web site. As it turns out, the site has a page-and-a-half statement that says he would rely on private markets and state leadership but gives no hint of what it would cost or who would pay. A one-page list of frequently asked questions about his Medicare plan assures us that “Mitt continues to work on refining the details.”

He continues to assert that his plan would cover people with pre-existing conditions when it clearly would not. People who have pre-existing conditions — and are not already covered by insurance — are often refused coverage or charged exorbitant rates by private insurers. Starting in 2014, the reform law will require insurers to accept all applicants and charge them without regard to health status. By contrast, Mr. Romney has simply pledged to protect people who had insurance but then lost it, provided they take out a new policy within a short time. But this protection is already required by law and offers absolutely nothing for millions of people who can’t get or can’t afford private insurance.

He has also implied that the reform law created an unelected board that’s “ultimately” going to tell people what treatments they can have. The advisory board is specifically precluded by the law from recommending cuts in benefits or eligibility; its job is to propose cuts in payments to providers and insurers if necessary to meet budget targets.

A major goal of the law was to cover some 30 million more people by expanding Medicaid and subsidizing coverage for middle-income people. That goal would be lost if the law was repealed. The Republicans, of course, have no plans for covering the uninsured beyond assuming they can use emergency rooms, leaving the problem to the states.

MEDICARE Mr. Romney has misrepresented what would happen to both current beneficiaries and future generations under his proposals. He says his plans would have no effect on people now on Medicare or nearing eligibility. But if he succeeded in repealing the reform law, which has many provisions that hold down costs for Medicare enrollees, most beneficiaries would see their annual premiums and cost-sharing go up. The average beneficiary in traditional Medicare would pay about $5,000 more through 2022, and heavy users of prescription drugs about $18,000 more over the same period, if the act is repealed, according to the Department of Health and Human Services. Department of Health and Human Services.

Mr. Romney also argues that the reform law will weaken Medicare because it cuts some $716 billion from future Medicare spending by slowing the rate of increase over the next decade. Of course, that is essentially the same amount of Medicare cuts in Mr. Ryan’s budget resolutions, approved this year and last year by House Republicans.

The reform law justifiably reduces the excessive subsidies to private plans (known as Medicare Advantage) that enroll many beneficiaries. It also lowers the annual rate of increase in payments to providers, like hospitals, nursing homes and home care agencies, to force them to become more efficient. Mr. Romney wants to keep overpaying the plans and providers simply to pander to elderly voters.

For future generations, the Romney-Ryan ticket would turn Medicare into a premium-support — or voucher — program in which the federal government provides a fixed amount of money to beneficiaries each year and allows it to grow by a small amount annually, which may not keep pace with medical costs. The whole point of turning to vouchers is to reduce federal spending on Medicare, so it seems likely that many beneficiaries would end up worse off than now. (At the vice-presidential debate, Mr. Ryan tried to pretend his premium-support proposal was bipartisan, but the sole Democrat who backed an early version — Senator Ron Wyden of Oregon — has disavowed his plan.)

Mr. Romney and Mr. Ryan insist that the magic of competition among health insurers — both private plans and a public option like Medicare — will bring down premiums. But if competition fails to do that, beneficiaries would almost certainly get socked with added payments or fewer benefits.

They say that lower-income beneficiaries would get more-generous premium support and wealthier individuals would receive less support. But, of course, they provide no numbers on what those support levels might be.

MEDICAID The Republicans want to repeal the reform law’s expansion of Medicaid to cover millions of low- and middle-income people and instead shrink federal funding by turning Medicaid into a block grant. States would be given a fixed amount of money equal to what they had been getting in federal payments for Medicaid, and that grant would then grow at a rate tied to inflation. If those increases failed to keep up with medical costs, states — faced with the necessity of balancing their budgets every year — would probably have to cut enrollments or benefits or payments to providers. That could include cuts to coverage for long-term and nursing home care that millions depend on.

The block grant proposal in Mr. Ryan’s budget resolution would reduce federal Medicaid payments to the states by more than $800 billion over 10 years and would cut federal funding by a third in 2022, according to the Center on Budget and Policy Priorities. Mr. Romney blithely said that if a state got into trouble “Why, we could step in and see if we could find a way to help them.” Or maybe not. It’s another of those vague promises.

This article has been revised to reflect the following correction:

Correction: October 21, 2012

An earlier version of this editorial misstated the additional amounts Medicare beneficiaries would pay if the health care reform act is repealed. The average beneficiary would pay about $5,000 more through 2022, not $4,200 more over the 2011-2012 period. Heavy prescription drug users, on average, would pay about $18,000 more through 2022, not $16,000 more over 2011-2012.