In Debate, Obama and Romney Clarify Positions on Medicare, Medicaid & Healthcare

First Presidential Debate - October 3, 2012So far, much of the punditry and commentary following the first U.S. Presidential Debate, which took place Wednesday, October 3 in Denver, has focused on the style, optics, and mannerisms of the candidates — not on the substance of what they said.

However, focusing on substance, the transcript of the debate shows that the candidates did clarify somewhat their respective positions on Medicare, Medicaid, and Healthcare.

Medicare

On Medicare, Governor Romney confirmed that his plan is to turn Medicare into a voucher program, at least for those who are now under age 55. He suggested that, as seniors, they would have a choice whether to accept a voucher and be obligated to buy health insurance on the private market or to participate in a program like the current Medicare. However, he did acknowledge that he would make cuts to that Medicare program. As an example, he indicated that benefits would need to be cut, at least for high income earners. His advisors have also suggested that the eligibility age for Medicare would be raised to 67, among other cuts.

Gov. Romney also repeated his, now discredited, claim that “on Medicare, for current retirees, [President Obama is] cutting $716 billion from the program.” (See e.g. Politifact, the LA Times, and USA Today, among many other fact checkers – all debunking Gov. Romney’s false claim that Obamacare cut $716 Billion from current retirees.)

President Obama stated that he does not favor turning Medicare into a voucher system, which could leave seniors at the mercy of private insurance companies driven by the profit motive and wind up costing them significantly more. He also pointed out that according to independent experts, a voucher system would also threaten the viability of Medicare and end up placing only the sickest seniors in that program. “And every health care economist that looks at it says, over time, what’ll happen is the traditional Medicare system will collapse,” the President said.

The President explained that his policies are to preserve and protect the current Medicare program and shore it up financially to extend its life and assure that it is available on a guaranteed basis for all current and future seniors. He explained that, as determined by the nonpartisan Congressional Budget Office, the Affordable Care Act did extend the life of Medicare by 8 years by saving $716 Billion in costs over the next 10 years. These savings come from reducing wasteful payments to insurance companies and hospitals, with their agreement. These savings do NOT cut benefits for retirees. In fact, the President pointed out, under the Affordable Care Act, Medicare benefits for seniors have been enhanced — including added prescription drug coverage, free preventive health care, and other benefits.

The President said that he does not view Social Security and Medicare as “entitlements” or believe that they foster “dependency” in seniors who rely on them in their older age. Citing his Grandmother as an example, he said she worked hard and paid into the system all her life, and “the reason she could be independent was because of Social Security and Medicare. She had worked all her life, put in this money, and understood that there was a basic guarantee, a floor under which she could not go.”

Following are the portions of the Presidential Debate Transcript provided by CNN, in which the candidates discussed their policies on Medicare:

“21:39:56: LEHRER: All right? All right. This is segment three, the economy. Entitlements. First — first answer goes to you, two minutes, Mr. President. Do you see a major difference between the two of you on Social Security?

21:40:15: OBAMA: You know, I suspect that, on Social Security, we’ve got a somewhat similar position. Social Security is structurally sound. It’s going to have to be tweaked the way it was by Ronald Reagan and Speaker — Democratic Speaker Tip O’Neill. But it is — the basic structure is sound.

But — but I want to talk about the values behind Social Security and Medicare, and then talk about Medicare, because that’s the big driver of our deficits right now.

You know, my grandmother — some of you know — helped to raise me. My grandparents did. My grandfather died a while back. My grandmother died three days before I was elected president. And she was fiercely independent. She worked her way up, only had a high school education, started as a secretary, ended up being the vice president of a local bank. And she ended up living alone by choice.

And the reason she could be independent was because of Social Security and Medicare. She had worked all her life, put in this money, and understood that there was a basic guarantee, a floor under which she could not go.

And that’s the perspective I bring when I think about what’s called entitlements. You know, the name itself implies some sense of dependency on the part of these folks. These are folks who’ve worked hard, like my grandmother, and there are millions of people out there who are counting on this.

So my approach is to say, how do we strengthen the system over the long term? And in Medicare, what we did was we said, we are going to have to bring down the costs if we’re going to deal with our long-term deficits, but to do that, let’s look where some of the money’s going.

$716 billion we were able to save from the Medicare program by no longer overpaying insurance companies by making sure that we weren’t overpaying providers. And using that money, we were actually able to lower prescription drug costs for seniors by an average of $600, and we were also able to make a — make a significant dent in providing them the kind of preventive care that will ultimately save money through the — throughout the system.

So the way for us to deal with Medicare in particular is to lower health care costs. When it comes to Social Security, as I said, you don’t need a major structural change in order to make sure that Social Security is there for the future.

21:42:38: LEHRER: We’ll follow up on this.

First, Governor Romney, you have two minutes on Social Security and entitlements.

21:42:41: ROMNEY: Well, Jim, our seniors depend on these programs, and I know anytime we talk about entitlements, people become concerned that something’s going to happen that’s going to change their life for the worse.

And the answer is neither the president nor I are proposing any changes for any current retirees or near retirees, either to Social Security or Medicare. So if you’re 60 or around 60 or older, you don’t need to listen any further.

But for younger people, we need to talk about what changes are going to be occurring. Oh, I just thought about one. And that is, in fact, I was wrong when I said the president isn’t proposing any changes for current retirees. In fact he is on Medicare. On Social Security he’s not.

But on Medicare, for current retirees, he’s cutting $716 billion from the program. Now, he says by not overpaying hospitals and providers. Actually just going to them and saying, “We’re going to reduce the rates you get paid across the board, everybody’s going to get a lower rate.” That’s not just going after places where there’s abuse. That’s saying we’re cutting the rates. Some 15 percent of hospitals and nursing homes say they won’t take anymore Medicare patients under that scenario.

We also have 50 percent of doctors who say they won’t take more Medicare patients.

This — we have 4 million people on Medicare Advantage that will lose Medicare Advantage because of those $716 billion in cuts. I can’t understand how you can cut Medicare $716 billion for current recipients of Medicare.

Now, you point out, well, we’re putting some back. We’re going to give a better prescription program. That’s $1 — that’s $1 for every $15 you’ve cut. They’re smart enough to know that’s not a good trade.

I want to take that $716 billion you’ve cut and put it back into Medicare. By the way, we can include a prescription program if we need to improve it.

But the idea of cutting $716 billion from Medicare to be able to balance the additional cost of Obamacare is, in my opinion, a mistake.

And with regards to young people coming along, I’ve got proposals to make sure Medicare and Social Security are there for them without any question.

21:44:43: LEHRER: Mr. President?

21:44:44: OBAMA: First of all, I think it’s important for Governor Romney to present this plan that he says will only affect folks in the future.

And the essence of the plan is that you would turn Medicare into a voucher program. It’s called premium support, but it’s understood to be a voucher program. His running mate…

21:45:05: LEHRER: And you don’t support that?

21:45:07: OBAMA: I don’t. And let me explain why.

21:45:08: ROMNEY: Again, that’s for future…

21:45:09: OBAMA: I understand.

21:45:10: ROMNEY: … people, right, not for current retirees.

21:45:12: OBAMA: For — so if you’re — if you’re 54 or 55, you might want to listen ’cause this — this will affect you.

The idea, which was originally presented by Congressman Ryan, your running mate, is that we would give a voucher to seniors and they could go out in the private marketplace and buy their own health insurance.

The problem is that because the voucher wouldn’t necessarily keep up with health care inflation, it was estimated that this would cost the average senior about $6,000 a year.

Now, in fairness, what Governor Romney has now said is he’ll maintain traditional Medicare alongside it. But there’s still a problem, because what happens is, those insurance companies are pretty clever at figuring out who are the younger and healthier seniors. They recruit them, leaving the older, sicker seniors in Medicare. And every health care economist that looks at it says, over time, what’ll happen is the traditional Medicare system will collapse.

And then what you’ve got is folks like my grandmother at the mercy of the private insurance system precisely at the time when they are most in need of decent health care.

So, I don’t think vouchers are the right way to go. And this is not my own — only my opinion. AARP thinks that the — the savings that we obtained from Medicare bolster the system, lengthen the Medicare trust fund by eight years. Benefits were not affected at all. And ironically, if you repeal Obamacare, and I have become fond of this term, “Obamacare,” if you repeal it, what happens is those seniors right away are going to be paying $600 more in prescription care. They’re now going to have to be paying copays for basic checkups that can keep them healthier.

And the primary beneficiary of that repeal are insurance companies that are estimated to gain billions of dollars back when they aren’t making seniors any healthier. And I don’t think that’s the right approach when it comes to making sure that Medicare is stronger over the long term.

21:47:21: LEHRER: We’ll talk about — specifically about health care in a moment. But what — do you support the voucher system, Governor?

21:47:27: ROMNEY: What I support is no change for current retirees and near-retirees to Medicare. And the president supports taking $716 billion out of that program.

21:47:32: LEHRER: And what about the vouchers?

(CROSSTALK)

21:47:36: ROMNEY: So that’s — that’s number one.

Number two is for people coming along that are young, what I do to make sure that we can keep Medicare in place for them is to allow them either to choose the current Medicare program or a private plan. Their choice.

They get to choose — and they’ll have at least two plans that will be entirely at no cost to them. So they don’t have to pay additional money, no additional $6,000. That’s not going to happen. They’ll have at least two plans.

And by the way, if the government can be as efficient as the private sector and offer premiums that are as low as the private sector, people will be happy to get traditional Medicare or they’ll be able to get a private plan.

I know my own view is I’d rather have a private plan. I’d just assume not have the government telling me what kind of health care I get. I’d rather be able to have an insurance company. If I don’t like them, I can get rid of them and find a different insurance company. But people make their own choice.

The other thing we have to do to save Medicare? We have to have the benefits high for those that are low income, but for higher income people, we’re going to have to lower some of the benefits. We have to make sure this program is there for the long term. That’s the plan that I’ve put forward.

And, by the way the idea came not even from Paul Ryan or — or Senator Wyden, who’s the co-author of the bill with — with Paul Ryan in the Senate, but also it came from Bill — Bill Clinton’s chief of staff. This is an idea that’s been around a long time, which is saying, hey, let’s see if we can’t get competition into the Medicare world so that people can get the choice of different plans at lower cost, better quality. I believe in competition.

21:49:05: OBAMA: Jim, if I — if I can just respond very quickly, first of all, every study has shown that Medicare has lower administrative costs than private insurance does, which is why seniors are generally pretty happy with it.

And private insurers have to make a profit. Nothing wrong with that. That’s what they do. And so you’ve got higher administrative costs, plus profit on top of that. And if you are going to save any money through what Governor Romney’s proposing, what has to happen is, is that the money has to come from somewhere.

And when you move to a voucher system, you are putting seniors at the mercy of those insurance companies. And over time, if traditional Medicare has decayed or fallen apart, then they’re stuck.

And this is the reason why AARP has said that your plan would weaken Medicare substantially. And that’s why they were supportive of the approach that we took.

One last point I want to make. We do have to lower the cost of health care, not just in Medicare and Medicaid… LEHRER: Talk about that in a minute.

OBAMA: … but — but — but overall.

LEHRER: OK.

OBAMA: And so…

ROMNEY: That’s — that’s a big topic. Can we — can we stay on Medicare?

OBAMA: Is that a — is that a separate topic?

(CROSSTALK)

LEHRER: Yeah, we’re going to — yeah, I want to get to it.

OBAMA: I’m sorry.

LEHRER: But all I want to do is go very quickly…

ROMNEY: Let’s get back to Medicare.

LEHRER: … before we leave the economy…

ROMNEY: Let’s get back to Medicare.

(CROSSTALK)

21:50:20: ROMNEY: The president said that the government can provide the service at lower cost and without a profit.

21:50:25: LEHRER: All right.

21:50:27: ROMNEY: If that’s the case, then it will always be the best product that people can purchase.

21:50:30: LEHRER: Wait a minute, Governor.

21:50:32: ROMNEY: But my experience — my experience the private sector typically is able to provide a better product at a lower cost.

21:50:38: LEHRER: All right. Can we — can the two of you agree that the voters have a choice — a clear choice between the two…

21:50:40: ROMNEY: Absolutely.

LEHRER: … of you on Medicare?

ROMNEY: Absolutely.

OBAMA: Absolutely.”

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Healthcare: The Patient Protection and Affordable Care Act (Obamacare)

Governor Romney confirmed his previously stated intention to “repeal Obamacare” on day one if he is elected President. He continued to refuse to be specific as to what he would replace it with. He did praise his own “Romneycare” system that was enacted in Massachusetts while he was Governor, suggesting that he would leave it up to the States whether to enact similar systems. As the President pointed out, Massachusetts’ Romneycare was essentially the model for Obamacare on the national level, with the same advisors having been instrumental in crafting both plans.

President Obama explained that, “if you repeal Obamacare, and I have become fond of this term, “Obamacare,” if you repeal it, what happens is those seniors [on Medicare] right away are going to be paying $600 more in prescription care. They’re now going to have to be paying copays for basic checkups that can keep them healthier.” “And the primary beneficiary of that repeal are insurance companies that are estimated to gain billions of dollars back when they aren’t making seniors any healthier. And I don’t think that’s the right approach when it comes to making sure that Medicare is stronger over the long term.”

He summarized some of what Obamacare does:

“And let me tell you exactly what Obamacare did. Number one, if you’ve got health insurance, it doesn’t mean a government takeover. You keep your own insurance. You keep your own doctor. But it does say insurance companies can’t jerk you around. They can’t impose arbitrary lifetime limits. They have to let you keep your kid on their insurance — your insurance plan until you’re 26 years old. And it also says that you’re going to have to get rebates if insurance companies are spending more on administrative costs and profits than they are on actual care.

Number two, if you don’t have health insurance, we’re essentially setting up a group plan that allows you to benefit from group rates that are typically 18 percent lower than if you’re out there trying to get insurance on the individual market.”

References to Obamacare were contained in the debate transcript quoted above. In addition, following are the principal portions of the Presidential Debate Transcript provided by CNN, which deal with Healthcare – the candidates’ positions on the Patient Protection & Affordable Care Act (or “Obamacare”):

21:55:55: LEHRER: All right. I think we have another clear difference between the two of you. Now, let’s move to health care where I know there is a clear difference, and that has to do with the Affordable Care Act, Obamacare. And it’s a two-minute new — new segment, and that means two minutes each. And you go first, Governor Romney.

You want it repealed. You want the Affordable Care Act repealed. Why?

21:56:20: ROMNEY: I sure do. Well, in part, it comes, again, from my experience. You know, I was in New Hampshire. A woman came to me and she said, look, I can’t afford insurance for myself or my son. I met a couple in Appleton, Wisconsin, and they said, we’re thinking of dropping our insurance, we can’t afford it.

And the number of small businesses I’ve gone to that are saying they’re dropping insurance because they can’t afford it, the cost of health care is just prohibitive. And — and we’ve got to deal with cost.

And, unfortunately, when — when — when you look at Obamacare, the Congressional Budget Office has said it will cost $2,500 a year more than traditional insurance. So it’s adding to cost. And as a matter of fact, when the president ran for office, he said that, by this year, he would have brought down the cost of insurance for each family by $2,500 a family. Instead, it’s gone up by that amount. So it’s expensive. Expensive things hurt families. So that’s one reason I don’t want it.

Second reason, it cuts $716 billion from Medicare to pay for it. I want to put that money back in Medicare for our seniors.

Number three, it puts in place an unelected board that’s going to tell people ultimately what kind of treatments they can have. I don’t like that idea.

Fourth, there was a survey done of small businesses across the country, said, what’s been the effect of Obamacare on your hiring plans? And three-quarters of them said it makes us less likely to hire people. I just don’t know how the president could have come into office, facing 23 million people out of work, rising unemployment, an economic crisis at the — at the kitchen table, and spend his energy and passion for two years fighting for Obamacare instead of fighting for jobs for the American people. It has killed jobs.

And the best course for health care is to do what we did in my state: craft a plan at the state level that fits the needs of the state. And then let’s focus on getting the costs down for people, rather than raising it with the $2,500 additional premium.

21:58:19: LEHRER: Mr. President, the argument against repeal?

21:58:20: OBAMA: Well, four years ago, when I was running for office, I was traveling around and having those same conversations that Governor Romney talks about. And it wasn’t just that small businesses were seeing costs skyrocket and they couldn’t get affordable coverage even if they wanted to provide it to their employees. It wasn’t just that this was the biggest driver of our federal deficit, our overall health care costs, but it was families who were worried about going bankrupt if they got sick, millions of families, all across the country.

If they had a pre-existing condition, they might not be able to get coverage at all. If they did have coverage, insurance companies might impose an arbitrary limit. And so as a consequence, they’re paying their premiums, somebody gets really sick, lo and behold, they don’t have enough money to pay the bills, because the insurance companies say that they’ve hit the limit.

So we did work on this, alongside working on jobs, because this is part of making sure that middle-class families are secure in this country.

And let me tell you exactly what Obamacare did. Number one, if you’ve got health insurance, it doesn’t mean a government takeover. You keep your own insurance. You keep your own doctor. But it does say insurance companies can’t jerk you around. They can’t impose arbitrary lifetime limits. They have to let you keep your kid on their insurance — your insurance plan until you’re 26 years old. And it also says that you’re going to have to get rebates if insurance companies are spending more on administrative costs and profits than they are on actual care.

Number two, if you don’t have health insurance, we’re essentially setting up a group plan that allows you to benefit from group rates that are typically 18 percent lower than if you’re out there trying to get insurance on the individual market.

Now, the last point I’d make before…

LEHRER: Two minutes — two minutes is up, sir.

OBAMA: No, I think — I had five seconds before you interrupted me, was …

(LAUGHTER)

… the irony is that we’ve seen this model work really well in Massachusetts, because Governor Romney did a good thing, working with Democrats in the state to set up what is essentially the identical model and as a consequence people are covered there. It hasn’t destroyed jobs. And as a consequence, we now have a system in which we have the opportunity to start bringing down costs, as opposed to just leaving millions of people out in the cold.

22:01:01: LEHRER: Your five seconds went away a long time ago.

All right, Governor. Governor, tell — tell the president directly why you think what he just said is wrong about Obamacare?

22:01:10: ROMNEY: Well, I did with my first statement.

(CROSSTALK)

22:01:13: ROMNEY: First of all, I like the way we did it in Massachusetts. I like the fact that in my state, we had Republicans and Democrats come together and work together. What you did instead was to push through a plan without a single Republican vote. As a matter of fact, when Massachusetts did something quite extraordinary — elected a Republican senator to stop Obamacare, you pushed it through anyway.

So entirely on a partisan basis, instead of bringing America together and having a discussion on this important topic, you pushed through something that you and Nancy Pelosi and Harry Reid thought was the best answer and drove it through.

What we did in a legislature 87 percent Democrat, we worked together; 200 legislators in my legislature, only two voted against the plan by the time we were finished. What were some differences? We didn’t raise taxes. You’ve raised them by $1 trillion under Obamacare. We didn’t cut Medicare. Of course, we don’t have Medicare, but we didn’t cut Medicare by $716 billion.

We didn’t put in place a board that can tell people ultimately what treatments they’re going to receive. We didn’t also do something that I think a number of people across this country recognize, which is put — put people in a position where they’re going to lose the insurance they had and they wanted.

Right now, the CBO says up to 20 million people will lose their insurance as Obamacare goes into effect next year. And likewise, a study by McKinsey and Company of American businesses said 30 percent of them are anticipating dropping people from coverage.

So for those reasons, for the tax, for Medicare, for this board, and for people losing their insurance, this is why the American people don’t want Medicare — don’t want Obamacare. It’s why Republicans said, do not do this, and the Republicans had — had the plan. They put a plan out. They put out a plan, a bipartisan plan. It was swept aside.

I think something this big, this important has to be done on a bipartisan basis. And we have to have a president who can reach across the aisle and fashion important legislation with the input from both parties.

22:03:12: OBAMA: Governor Romney said this has to be done on a bipartisan basis. This was a bipartisan idea. In fact, it was a Republican idea. And Governor Romney at the beginning of this debate wrote and said what we did in Massachusetts could be a model for the nation.

And I agree that the Democratic legislators in Massachusetts might have given some advice to Republicans in Congress about how to cooperate, but the fact of the matter is, we used the same advisers, and they say it’s the same plan.

It — when Governor Romney talks about this board, for example, unelected board that we’ve created, what this is, is a group of health care experts, doctors, et cetera, to figure out, how can we reduce the cost of care in the system overall?

Because there — there are two ways of dealing with our health care crisis. One is to simply leave a whole bunch of people uninsured and let them fend for themselves, to let businesses figure out how long they can continue to pay premiums until finally they just give up, and their workers are no longer getting insured, and that’s been the trend line.

Or, alternatively, we can figure out, how do we make the cost of care more effective? And there are ways of doing it.

So at Cleveland Clinic, one of the best health care systems in the world, they actually provide great care cheaper than average. And the reason they do is because they do some smart things. They — they say, if a patient’s coming in, let’s get all the doctors together at once, do one test instead of having the patient run around with 10 tests. Let’s make sure that we’re providing preventive care so we’re catching the onset of something like diabetes. Let’s — let’s pay providers on the basis of performance as opposed to on the basis of how many procedures they’ve — they’ve engaged in.

Now, so what this board does is basically identifies best practices and says, let’s use the purchasing power of Medicare and Medicaid to help to institutionalize all these good things that we do.

And the fact of the matter is that, when Obamacare is fully implemented, we’re going to be in a position to show that costs are going down. And over the last two years, health care premiums have gone up — it’s true — but they’ve gone up slower than any time in the last 50 years. So we’re already beginning to see progress. In the meantime, folks out there with insurance, you’re already getting a rebate.

Let me make one last point. Governor Romney says, we should replace it, I’m just going to repeal it, but — but we can replace it with something. But the problem is, he hasn’t described what exactly we’d replace it with, other than saying we’re going to leave it to the states.

But the fact of the matter is that some of the prescriptions that he’s offered, like letting you buy insurance across state lines, there’s no indication that that somehow is going to help somebody who’s got a pre-existing condition be able to finally buy insurance. In fact, it’s estimated that by repealing Obamacare, you’re looking at 50 million people losing health insurance…

22:06:24: LEHRER: Let’s…

22:06:25: OBAMA: … at a time when it’s vitally important.

22:06:26: LEHRER: Let’s let the governor explain what you would do…

22:06:27: ROMNEY: Well…

22:06:28: LEHRER: … if Obamacare is repealed. How would you replace it?

(CROSSTALK)

22:06:33: ROMNEY: Well, actually it’s — it’s — it’s a lengthy description. But, number one, preexisting 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.

But let’s come back to something the president and I agree on, which is the key task we have in health care is to get the cost down so it’s more affordable for families. And then he has as a model for doing that a board of people at the government, an unelected board, appointed board, who are going to decide what kind of treatment you ought to have.

(CROSSTALK)

In my opinion, the government is not effective in — in bringing down the cost of almost anything. As a matter of fact, free people and free enterprises trying to find ways to do things better are able to be more effective in bringing down the cost than the government will ever be.

Your example of the Cleveland Clinic is my case in point, along with several others I could describe.

This is the private market. These are small — these are enterprises competing with each other, learning how to do better and better jobs. I used to consult to businesses — excuse me, to hospitals and to health care providers. I was astonished at the creativity and innovation that exists in the American people.

In order to bring the cost of health care down, we don’t need to have a board of 15 people telling us what kinds of treatments we should have. We instead need to put insurance plans, providers, hospitals, doctors on target such that they have an incentive, as you say, performance pay, for doing an excellent job, for keeping costs down, and that’s happening. Innermountain Healthcare does it superbly well, Mayo Clinic is doing it superbly well, Cleveland Clinic, others.

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.

22:08:36: OBAMA: Let me just point out first of all this board that we’re talking about can’t make decisions about what treatments are given. That’s explicitly prohibited in the law. But let’s go back to what Governor Romney indicated, that under his plan, he would be able to cover people with preexisting conditions.

Well, actually Governor, that isn’t what your plan does. What your plan does is to duplicate what’s already the law, which says if you are out of health insurance for three months, then you can end up getting continuous coverage and an insurance company can’t deny you if you’ve — if it’s been under 90 days.

But that’s already the law and that doesn’t help the millions of people out there with preexisting conditions. There’s a reason why Governor Romney set up the plan that he did in Massachusetts. It wasn’t a government takeover of health care. It was the largest expansion of private insurance. But what it does say is that “insurers, you’ve got to take everybody.”

Now, that also means that you’ve got more customers. But when — when Governor Romney says that he’ll replace it with something, but can’t detail how it will be in fact replaced and the reason he set up the system he did in Massachusetts was because there isn’t a better way of dealing with the preexisting conditions problem.

It just reminds me of, you know, he says that he’s going to close deductions and loopholes for his tax plan. That’s how it’s going to be paid for, but we don’t know the details. He says that he’s going to replace Dodd-Frank, Wall Street reform, but we don’t know exactly which ones. He won’t tell us. He now says he’s going to replace Obamacare and ensure that all the good things that are in it are going to be in there and you don’t have to worry.

And at some point, I think the American people have to ask themselves, is the reason that Governor Romney is keeping all these plans to replace secret because they’re too good? Is it — is it because that somehow middle-class families are going to benefit too much from them?

No. The reason is, is because, when we reform Wall Street, when we tackle the problem of pre-existing conditions, then, you know, these are tough problems and we’ve got to make choices. And the choices we’ve made have been ones that ultimately are benefiting middle-class families all across the country.

22:11:05: LEHRER: We’re going to move to…”

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Medicaid

Governor Romney doubled down on his previous proposals to end the Federal Medicaid program as we know it, and turn it into a block grant program leaving it up to the States whether to continue providing Medicaid, and if so, pushing all responsibility to administer it to the States, with federal funding capped by a formula pegged to inflation. He said, “I would like to take the Medicaid dollars that go to states and say to a state, you’re going to get what you got last year, plus inflation, plus 1 percent, and then you’re going to manage your care for your poor in the way you think best.”

President Obama explained that Governor Romney’s proposal to send Medicaid back to the States “effectively … means a 30 percent cut in the primary program we help for seniors who are in nursing homes, for kids who are with disabilities. . . . — and that is not a right strategy for us to move forward.” “Now, you know, that may not seem like a big deal when it just is, you know, numbers on a sheet of paper, but if we’re talking about a family who’s got an autistic kid and is depending on that Medicaid, that’s a big problem,” the President said. “And governors are creative. There’s no doubt about it. But they’re not creative enough to make up for 30 percent of revenue on something like Medicaid. What ends up happening is some people end up not getting help.”

The President explained that his proposals are to continue to preserve and protect the Medicaid and Medicare programs and to extend their lives by shoring up their finances through a balanced fiscal approach and a continued focus on cutting waste, fraud and abuse in the system. He cited examples of successes in doing this during his first four years in office.

Following are portions of the Presidential Debate Transcript provided by CNN, in which the candidates discussed their positions and proposals for Medicaid:

“21:28:35: LEHRER: Mr. President, two minutes.

21:28:37: OBAMA: When I walked into the Oval Office, I had more than a trillion-dollar deficit greeting me. And we know where it came from: two wars that were paid for on a credit card; two tax cuts that were not paid for; and a whole bunch of programs that were not paid for; and then a massive economic crisis.

And despite that, what we’ve said is, yes, we had to take some initial emergency measures to make sure we didn’t slip into a Great Depression, but what we’ve also said is, let’s make sure that we are cutting out those things that are not helping us grow.

So 77 government programs, everything from aircrafts that the Air Force had ordered but weren’t working very well, 18 government — 18 government programs for education that were well-intentioned, not weren’t helping kids learn, we went after medical fraud in Medicare and Medicaid very aggressively, more aggressively than ever before, and have saved tens of billions of dollars, $50 billion of waste taken out of the system.

And I worked with Democrats and Republicans to cut a trillion dollars out of our discretionary domestic budget. That’s the largest cut in the discretionary domestic budget since Dwight Eisenhower.

Now, we all know that we’ve got to do more. And so I’ve put forward a specific $4 trillion deficit reduction plan. It’s on a website. You can look at all the numbers, what cuts we make and what revenue we raise.

And the way we do it is $2.50 for every cut, we ask for $1 of additional revenue, paid for, as I indicated earlier, by asking those of us who have done very well in this country to contribute a little bit more to reduce the deficit. Governor Romney earlier mentioned the Bowles-Simpson commission. Well, that’s how the commission — bipartisan commission that talked about how we should move forward suggested we have to do it, in a balanced way with some revenue and some spending cuts. And this is a major difference that Governor Romney and I have.

Let — let me just finish their point, because you’re looking for contrast. You know, when Governor Romney stood on a stage with other Republican candidates for the nomination and he was asked, would you take $10 of spending cuts for just $1 of revenue? And he said no.

Now, if you take such an unbalanced approach, then that means you are going to be gutting our investments in schools and education. It means that Governor Romney…

(CROSSTALK)

21:31:15: OBAMA: … talked about Medicaid and how we could send it back to the states, but effectively this means a 30 percent cut in the primary program we help for seniors who are in nursing homes, for kids who are with disabilities.

21:31:22: LEHRER: Mr. President, I’m sorry.

21:31:26: OBAMA: And — and that is not a right strategy for us to move forward.

21:31:28: LEHRER: Way over the two minutes.

21:31:28: OBAMA: Sorry.

21:31:34: LEHRER: Governor, what about Simpson-Bowles? Do you support Simpson-Bowles?

21:31:34: ROMNEY: Simpson-Bowles, the president should have grabbed that.

21:31:35: LEHRER: No, I mean, do you support Simpson-Bowles?

21:31:36: ROMNEY: I have my own plan. It’s not the same as Simpson- Bowles. But in my view, the president should have grabbed it. If you wanted to make some adjustments to it, take it, go to Congress, fight for it.

21:31:48: OBAMA: That’s what we’ve done, made some adjustments to it, and we’re putting it forward before Congress right now, a $4 trillion plan…

ROMNEY: But you’ve been — but you’ve been president four years…

(CROSSTALK)

21:31:54: ROMNEY: You’ve been president four years. You said you’d cut the deficit in half. It’s now four years later. We still have trillion-dollar deficits. The CBO says we’ll have a trillion-dollar deficit each of the next four years. If you’re re-elected, we’ll get to a trillion-dollar debt.

I mean, you have said before you’d cut the deficit in half. And this — I love this idea of $4 trillion in cuts. You found $4 trillion of ways to reduce or to get closer to a balanced budget, except we still show trillion-dollar deficits every year. That doesn’t get the job done.

Let me come back and say, why is it that I don’t want to raise taxes? Why don’t I want to raise taxes on people? And actually, you said it back in 2010. You said, “Look, I’m going to extend the tax policies that we have now; I’m not going to raise taxes on anyone, because when the economy is growing slow like this, when we’re in recession, you shouldn’t raise taxes on anyone.”

Well, the economy is still growing slow. As a matter of fact, it’s growing much more slowly now than when you made that statement. And so if you believe the same thing, you just don’t want to raise taxes on people. And the reality is it’s not just wealthy people — you mentioned Donald Trump. It’s not just Donald Trump you’re taxing. It’s all those businesses that employ one-quarter of the workers in America; these small businesses that are taxed as individuals.

You raise taxes and you kill jobs. That’s why the National Federation of Independent Businesses said your plan will kill 700,000 jobs. I don’t want to kill jobs in this environment.

I’ll make one more point.

(CROSSTALK)

21:33:21: LEHRER: (inaudible) answer the taxes thing for a moment.

21:33:22: ROMNEY: OK.

21:33:23: LEHRER: Mr. President?

21:33:24: OBAMA: Well, we’ve had this discussion before.

21:33:26: LEHRER: About the idea that in order to reduce the deficit, there has to be revenue in addition to cuts.

21:33:30: OBAMA: There has to be revenue in addition to cuts. Now, Governor Romney has ruled out revenue. He’s ruled out revenue.

(CROSSTALK)

21:33:31: ROMNEY: Absolutely. (CROSSTALK)

21:33:30: ROMNEY: Look, the revenue I get is by more people working, getting higher pay, paying more taxes. That’s how we get growth and how we balance the budget. But the idea of taxing people more, putting more people out of work, you’ll never get there. You’ll never balance the budget by raising taxes.

Spain — Spain spends 42 percent of their total economy on government. We’re now spending 42 percent of our economy on government. I don’t want to go down the path to Spain. I want to go down the path of growth that puts Americans to work with more money coming in because they’re working.

21:34:11: LEHRER: But — but Mr. President, you’re saying in order to — to get the job done, it’s got to be balanced. You’ve got to have…

(CROSSTALK)

21:34:16: OBAMA: If — if we’re serious, we’ve got to take a balanced, responsible approach. And by the way, this is not just when it comes to individual taxes. Let’s talk about corporate taxes.

Now, I’ve identified areas where we can, right away, make a change that I believe would actually help the economy.

The oil industry gets $4 billion a year in corporate welfare. Basically, they get deductions that those small businesses that Governor Romney refers to, they don’t get.

Now, does anybody think that ExxonMobil needs some extra money, when they’re making money every time you go to the pump? Why wouldn’t we want to eliminate that? Why wouldn’t we eliminate tax breaks for corporate jets? My attitude is, if you got a corporate jet, you can probably afford to pay full freight, not get a special break for it.

When it comes to corporate taxes, Governor Romney has said he wants to, in a revenue neutral way, close loopholes, deductions — he hasn’t identified which ones they are — but that thereby bring down the corporate rate.

Well, I want to do the same thing, but I’ve actually identified how we can do that. And part of the way to do it is to not give tax breaks to companies that are shipping jobs overseas.

Right now, you can actually take a deduction for moving a plant overseas. I think most Americans would say that doesn’t make sense. And all that raises revenue.

And so if we take a balanced approach, what that then allows us to do is also to help young people, the way we already have during my administration, make sure that they can afford to go to college.

It means that the teacher that I met in Las Vegas, a wonderful young lady, who describes to me — she’s got 42 kids in her class. The first two weeks she’s got them, some of them sitting on the floor until finally they get reassigned. They’re using text books that are 10 years old.

That is not a recipe for growth. That’s not how America was built. And so budgets reflect choices.

Ultimately, we’re going to have to make some decisions. And if we’re asking for no revenue, then that means that we’ve got to get rid of a whole bunch of stuff.

And the magnitude of the tax cuts that you’re talking about, Governor, would end up resulting in severe hardship for people, but more importantly, would not help us grow.

As I indicated before, when you talk about shifting Medicaid to states, we’re talking about potentially a 30 — a 30 percent cut in Medicaid over time.

Now, you know, that may not seem like a big deal when it just is, you know, numbers on a sheet of paper, but if we’re talking about a family who’s got an autistic kid and is depending on that Medicaid, that’s a big problem.

And governors are creative. There’s no doubt about it. But they’re not creative enough to make up for 30 percent of revenue on something like Medicaid. What ends up happening is some people end up not getting help.

21:37:19: ROMNEY: Jim, let’s — we’ve gone on a lot of topics there, and so it’s going to take a minute to go from Medicaid to schools…

21:37:22: LEHRER: Come back to…

(CROSSTALK)

21:37:25: ROMNEY: … to oil, to tax breaks, then companies going overseas. So let’s go through them one by one.

First of all, the Department of Energy has said the tax break for oil companies is $2.8 billion a year. And it’s actually an accounting treatment, as you know, that’s been in place for a hundred years. Now…

OBAMA: It’s time to end it.

ROMNEY: And in one year, you provided $90 billion in breaks to the green energy world.

Now, I like green energy as well, but that’s about 50 years’ worth of what oil and gas receives. And you say Exxon and Mobil. Actually, this $2.8 billion goes largely to small companies, to drilling operators and so forth.

But, you know, if we get that tax rate from 35 percent down to 25 percent, why that $2.8 billion is on the table. Of course it’s on the table. That’s probably not going to survive you get that rate down to 25 percent.

But don’t forget, you put $90 billion, like 50 years’ worth of breaks, into — into solar and wind, to Solyndra and Fisker and Tester and Ener1. I mean, I had a friend who said you don’t just pick the winners and losers, you pick the losers, all right? So this — this is not — this is not the kind of policy you want to have if you want to get America energy secure.

The second topic, which is you said you get a deduction for taking a plant overseas. Look, I’ve been in business for 25 years. I have no idea what you’re talking about. I maybe need to get a new accountant.

LEHRER: Let’s…

ROMNEY: But — but the idea that you get a break for shipping jobs overseas is simply not the case.

(CROSSTALK)

ROMNEY: What we do have right now is a setting where I’d like to bring money from overseas back to this country.

And, finally, Medicaid to states? I’m not quite sure where that came in, except this, which is, I would like to take the Medicaid dollars that go to states and say to a state, you’re going to get what you got last year, plus inflation, plus 1 percent, and then you’re going to manage your care for your poor in the way you think best.

And I remember, as a governor, when this idea was floated by Tommy Thompson, the governors — Republican and Democrats — said, please let us do that. We can care for our own poor in so much better and more effective a way than having the federal government tell us how to care for our poor.

So — so let’s state — one of the magnificent things about this country is the whole idea that states are the laboratories of democracy. Don’t have the federal government tell everybody what kind of training programs they have to have and what kind of Medicaid they have to have. Let states do this.”

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More Information

For the full transcript of the first Presidential Debate, held in Denver on October 3, 2012, see CNN’s Transcript of Wednesday’s presidential debate.

For Fact Checking of the debate, see:

For more news and information about the Patient Protection & Affordable Care Act, President Obama’s signature Health Care Law, and about health care reform, see the HelpingYouCare® resource pages on VoicesForCare™, including:

For More information on Medicare, Medicaid, health and long-term care insurance, and other financial issues, see the HelpingYouCare® resource pages on Financial Issues for Caregivers & Seniors, including:

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