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It's about Obamacare, not the economy

Both parties, but particularly the Republicans, emphasize how this election is all about the economy. Voters overwhelming say the economy is their No.
With the Capitol in the background, Republican presidential candidate, former Massachusetts Gov. Mitt Romney leaves after speaking about the Supreme Court's health care ruling, Thursday, June 28, 2012, in Washington. (AP Photo/Charles Dharapak)
With the Capitol in the background, Republican presidential candidate, former Massachusetts Gov. Mitt Romney leaves after speaking about the Supreme Court's...

Both parties, but particularly the Republicans, emphasize how this election is all about the economy. Voters overwhelming say the economy is their No. 1 consideration in picking a candidate. President Barack Obama and Gov. Mitt Romney spend most of their time on the campaign trail touting economic plans. Obama argues he has already put the economy on the right track while Romney says 12 million jobs will be created under his watch.

But in truth, presidents have very little control over the economy. No presidential candidate can definitively say a certain number of jobs will be created while they are in office. Factors totally out of their control (the Internet boom during the Clinton years, the Wall Street meltdown President Obama inherited) can have huge influences on the economy. Romney can safely claim to create 12 million jobs in part because non-partisan analysts suggest the American economy will improve and create about that many jobs no matter who is president.

In fact, this is the health care election, or more bluntly, the "Obamacare" election. On no issue are the candidates further apart. Obama pledges to implement his massive health care reform and Romney plans to gut it.

There are few issues where the government has more direct power. Under Obama's health care law, the government is already requiring health insurance companies to let young adults stay on their parents' health care plans until they are 26 years old.

When fully implemented over the next several years, the law will provide subsidies to people who can't afford insurance; give states billions to put more people on Medicaid; coordinate with states to set up new rules on what health insurance plans must cover; impose a number of regulations on health care companies, most notably that they can't charge higher prices for people who already have illnesses; and change how doctors and hospitals are paid under Medicare.

Some have dismissed Romney's plans to repeal the president's health care law, saying he would not pursue it in office. In fact, this is one of the highest-priorities of Republican activists and members of Congress. Romney would have to at least attempt to repeal the law.

And if Republicans have 50 seats in the Senate, they could join with a Vice President Paul Ryan and use a procedure in the Senate called reconciliation to eliminate much of the Affordable Care Act. (Here's an ex-adviser to former president George W. Bush explaining how Republicans could eliminate most of Obamacare with 51 votes in the Senate, not the 60 required for most provisions.)

If Democrats remained in control of at least one chamber in Congress (likely the Senate), they could probably stop Romney from repealing the law. But, that's not the only way he could weaken it.

Much of the implementation of the law requires heavy government intervention. Under the law, state governments are supposed to set up "exchanges" that would create new rules and a market that would make it easier for people to shop for health plans and purchase them. Some state governors, many of whom are Republicans, are threatening not to set up the exchanges.

Under the law, the federal government can set up an exchange for a state. President Obama would certainly use federal power to create these exchanges, while Romney would be under enormous pressure from conservatives not to. This is an important distinction, the Congressional Budget Office estimates as many as 25 million Americans would get coverage through these exchanges by 2016.

Similarly, the Supreme Court's ruling on Obamacare said states can, but don't have to accept new federal funds for Medicaid, which was originally projected to provide coverage for more than 15 million new people under the new law. By not accepting the money, these states would be denying themselves billions to cover the uninsured. Many GOP governors face political pressure not to accept the money or are ideologically opposed to Medicaid. Obama would of course look for ways to convince the governors, perhaps by giving states flexibility or waivers in how they create their Medicaid programs.

Romney, having pledged to dump the entire law, would face conservative pressure either to limit the expansion of Medicaid or give Republican governors almost complete control in how they implement the program.

“If President Obama is re-elected, Leavitt Partners believes the administration will do everything in its power to incentivize states to opt in to the full Medicaid expansion, offering program flexibility as needed. Under this scenario, most states will ultimately choose to expand their Medicaid programs, although some Republican states will be slow to move," according to a report written by a consulting firm operated by Michael Leavitt, who was Secretary of Health and Human Services under George. Bush and is now a top Romney adviser. The report was obtained by The New York Times.

The report, according to the Times, adds: "If Republicans take both the White House and Congress, Leavitt Partners believes the administration and Congress will effectively repeal the Medicaid expansion” or reduce the amount of federal money available, so “the expansion will no longer be an attractive option for most states.”

President Obama is not defining this choice on health care that starkly on the campaign trail. He is largely not talking at all about Obamacare, which remains very controversial, opposed by many Republicans and independents. Romney constantly notes he would repeal the health law, but also spends most of his time talking about the economy.

But this issue is perhaps the most stark difference between the candidates, particularly on an issue on which the next president will have huge influence. The future of the American health care system will be defined on Nov. 6.