ELECTION BLOG: Presidential perspectives from physicians, health care professionals

The following blog features presidential election perspectives - gathered before the results were in - from a wide range of specialists and health care providers. 

8 p.m.: My O&P practice and those practices of most AABCP members have put major business decisions (employment, budgeting, purchasing and contracting decisions) on hold until after the election. And depending on the outcome, many AABCP post-mastectomy boutiques are considering reducing their reach or closing their doors due to the taxes, business fees, health care coverage changes and regulations that are currently in place or which will go into effect without a significant policy shift. Although my practice will continue, for many, this election literally means entrepreneurial life and death.

– Rhonda F. Turner, PhD, JD, BOCPO, CFom, Executive Director, American Association of Breast Care Professionals

7:25 p.m.: The key will be whether/which reforms of the Affordable Care Act will proceed or be reversed. Although not all portions of the bill are necessarily optimal, there are many issues of importance for patients with stroke or heart disease that are addressed. Patients with cardiovascular disease have been particularly vulnerable. Those with congenital heart disease faced lifetime benefit caps and were then uninsurable because of pre-existing conditions. All who had a cardiovascular event or stroke could be denied renewal. Children lost their parent’s coverage once emancipated and could not afford other insurance. All patients benefit from enhanced coverage for preventive services. Meaningful use is spurring adoption or electronic health records which will hopefully improve the availability of patient information at critical times.

– Larry B. Goldstein, MD, cardiologist in North Carolina; Cardiology Today, Editorial Board member

7:13 p.m.: Although I have no idea what the first thing the next President, whom I'm fervently hoping will be our present President, should do concerning the Health Care Reform Act, whatever it is, it should be something that is politically possible under the present extremely dysfunctional and divided political system. However, the most important thing he can do in the long run is to control the runaway cost of health care as we now have it. This will require the profession to continue to promote evidence-based medicine, eliminating redundant testing that adds nothing to the information the physician needs to diagnose and the patient, and continuing to reduce the administrative costs involved in paying for health care. The worst thing that happened to medicine is that we began thinking of it as a business, and good business requires a profit. The high administrative costs occur because of the private health care insurance system we have and would be significantly improved by establishing a single-payer system. Unfortunately, we don't seem to be able to politically accomplish this. Another thing that should be reemphasized is that medical practice will be the same no matter how we pay for it and the fear tactic that those against single-payer systems use, that the way doctors treat patients will markedly change, is just wrong.

As far as the impact on my patients of this election is concerned, if Romney wins and dismantles much of the Health Care Reform Act, the effect on my patients will be tremendous and bad. I am on the faculty of University of California, San Francisco and my hospital is San Francisco General Hospital. We presently care for all patients who come to us. Many have no insurance and so the deficits at the end of the year are partly made by money from the city-county, which means from the general fund. With the plan fazing in now, we will have true insurance where everybody has to have medical insurance. This will mean that the cost of care is spread over everyone. It also means that people will come for medical care soon run the course of their disease, and many more will get preventive care, all of which makes the eventual cost of medical care less. The argument that young people will not use the insurance is correct. At any year, only 15% of the population sues the insurance. The fact is that eventually everyone at some point becomes one of the 15%. Republicans are against the requirement that everyone has medical insurance, so if Romney wins, we stay with the old system and reimbursement to all hospitals will depend on the ones who have insurance with their costs increased to help defray the medical costs of those without insurance. 

– Melvin Cheitlin, MD, cardiologist in San Francisco; Cardiology Today, Editorial Board member

7 p.m.: Regardless of who is elected today, many patients will be downright scared that health care reform will bring them a loss of benefits, a lack of choice, and increased out-of-pocket costs. In the short term, though, none of these is likely to happen. Instead, we need to ready our patients for the more likely reality.

In the past few weeks I have had several patients ask that I perform cataract surgery before year’s end, even though they have few symptoms of visual disturbance. Explaining their reasoning for hasty surgery, they make it clear that they’re afraid Medicare will go away under the Health Care Reform Act.

As physicians, part of our duty is to educate our patients on the realities of health care reform, both good and bad. We can and should encourage patients to contact their lawmakers, advocating for sensible health care reform measure. As before and above all, we need to help our patients make personal health care decisions based on fact and common sense.

It’s unlikely the Affordable Health Care Act will be repealed in the near term, regardless of who is elected. As physicians, we need to ready our practices, but we also need to show leadership in our communities and among our patients, who trust us most to be informed and to share common sense.

– John A. Hovanesian, MD, FACS, OSN Cataract Surgery, Section Editor

6:45 p.m.: The next president should uphold (as the Supreme Court did on June 28, 2012) and strengthen the Affordable Care Act (ACA); however, the next president should incorporate criticism and ideas from both sides of the table to continue to improve the plan. The ACA needs to be reviewed and enhanced with further work on a viable payment plan for interdisciplinary care, considerations on how the system and providers will manage a potential large influx of newly insured patients in conjunction with decreases in payments, by making real reforms in limiting medical malpractice and by reducing unnecessary procedures and variations in practice. The ACA is not perfect in its solutions for cost savings and quality improvement, but it is a very strong and bold start to caring for the most vulnerable of our population and shifting the health care focus toward wellness and interdisciplinary practice and care. It is about caring for all of our citizens. We could not afford to wait any longer to enact significant health care reform that has positive changes for those with pre-existing conditions, the disabled, and citizens without health care insurance. Though the full economic and health benefits of the reform will not be known for years, it will have immediate benefits for many older adults. November’s issue of the Journal of Gerontological Nursing has an editorial by Abraham Brody, PhD, RN, GNP-BC, and the new dean of New York University’s College of Nursing, Eileen Sullivan-Marx, PhD, RN, FAAN (Past Health and Aging Policy Fellow) on how the ACA Supreme Court decision impacts older adults, including the support of models of care that enable improved care coordination and the addition of an annual wellness visit fully covered under Medicare. Read it to learn more!

– Donna M. Fick, PhD, RN, FGSA, FAAN; Journal of Gerontological Nursing, editor; associate professor of nursing, College of Health and Human Development; associate professor of medicine, department of psychiatry, The Pennsylvania State University, University Park

6:28 p.m.: The next president should concentrate on reducing end of life care. There is so much money that is wasted on this area. We should do more for preventive care and screening for cancer. Also we should reduce obesity.

I thought that all issues regarding health care were not mentioned that much during the campaign.

– Peter Mavrelis, MD, gastroenterologist in Indiana

6:12 p.m.: This election will be an historic benchmark for how patients are willing to accept the delivery of their health care. The two candidates have completely different views on how to deliver and implement the country’s health care. The last many months patients have been exposed to two different concepts and they are very confused on how each concept is going to affect their own care and the care of this country. God bless America, and please vote.

– Arthur A. Medina Jr., OD, optometrist in San Antonio; Primary Care Optometry News, Editorial Board member

5:58 p.m.: The Affordable Care Act (ACA) is already fundamentally changing health care and aspects of it seem almost certain to continue regardless of the election results. Electronic medical records won’t go away and the linkage of medical center reimbursements based in part on issues important to the ID community, like hospital-acquired infections and early readmissions, will also be here for quite some time. The Supreme Court decisions, while allowing the ACA to move forward, introduced significant state-by-state variations particularly in Medicaid, which is also likely to continue adding major challenges to predicting the ultimate relationship between the ACA and the federal Ryan White Care Act coverage. Again, these complexities are unlikely to be quickly impacted by the election results. The gorilla in the room, and one that may well be affected by the election, is the increasingly urgent need to control health care costs. The ACA began to address this but did so by expanding the base of those with health insurance coverage. This, if successful, may allow subsequent changes in reimbursement mechanisms that could reduce cost, but the ACA doesn’t do this directly. Whatever controversy the ACA has generated will pale by comparison with any changes that actually reduce reimbursements to physicians and medical centers or limit the range of choices in testing, medications or procedures allowed in individual care. While expanding coverage will probably continue with either party controlling the White House, actually dealing with care costs may be quite different, with any real change requiring such political capital that will continue to test our national will.

– Paul Volberding, MD, professor of medicine, director of the Center for AIDS Research, University of California, San Francisco; Infectious Disease News, Chief Medical Editor

5:05 p.m.: My patients’ fates may take two divergent paths depending on the results of the election. Romney has a focus on the individual and will permit more variation across states when it comes to coverage of its people. There will be no federal enforcement that individual states enact universal health care or cover individuals with pre-existing medical conditions, regardless of how banal they are. “Obamacare” will continue to decrease the numbers of uninsured Americans with an aim of affordable health care for all, and is building the heft to enforce this vision. From an infectious disease point of view, I like the attention already paid by “Obamacare” to Pap testing, and HIV and STD counseling and testing.

As a practicing infectious disease doctor, I am worried that waiting lists to be seen for my HIV-infected patients will increase under Romney. With fewer people brought under direct immediate HIV care, more infections will occur as fewer source patients are identified and treated. Patients may present with later complications of AIDS (opportunistic infections and malignancies). I am worried that vaccinations will not be provided to all in Romney’s health care world. I asked my friend and colleague Jeff Klausner, MD, professor of medicine at UCLA, and he agrees: “With Romney, consequences of chronic diseases might increase due to lack of access to preventive health care.”

Well, almost all chronic diseases. It was interesting that one of the few infectious diseases to get any attention in the election runoff was “chronic” Lyme disease. In a campaign mailer in Northern Virginia, Romney promised to address this “epidemic that was wreaking havoc.” He plans to “encourage increased options for the treatment of Lyme disease [so that physicians] can treat the disease with the aggressive antibiotics that are required.” Perhaps one infectious disease will get some more funding under Romney.

– Peter Chin-Hong, MD, associate professor of clinical medicine; University of California, San Francisco School of Medicine; Infectious Disease News, Editorial Board member

4:48 p.m.: The repercussions of the election outcome this year have shifted back and forth about being about the economy versus health care reform. The closer truth is it is about both the economy and health care reform. They are inexplicably related since the United States has the highest per-capita costs for health care expenses but fares poorly on health care quality measures when compared with the rest of the world. Both of these issues profoundly impact health care and nursing practice.

One of the promises Gov. Romney has made is that he will overturn the Affordable Care Act (ACA) if he is elected today, saying that it will put too much burden on the health care system and on small businesses that are already struggling. It is unlikely that overturning the ACA would be an easy task regardless of the election results, but the ACA provides many opportunities for nurses (increased funding for nursing education and workforce development and increases in funding nurse-led health centers are just a few examples), yet it also needs to go further in explicating the important roles nurses play in our health care system.

Nursing research and nursing education could feel an immediate impact in potential decreases in funding depending on the results of today’s election. Nurses at the bedside will likely not feel an immediate impact from the election results, but I believe strengthening the ACA will lead to positive long-term changes for bedside nursing practice and our health care system. Nurses should cast their ballots early today, as their vote will make a direct and long-lasting impact on the future of nursing practice!

– Donna M. Fick, PhD, RN, FGSA, FAAN; Journal of Gerontological Nursing, Editor; associate professor of nursing, College of Health and Human Development; associate professor of medicine, department of psychiatry, The Pennsylvania State University, University Park

4:35 p.m.: Each candidate “tip-toed” around details regarding the needed Medicare reform that will be necessary to make and keep it solvent. Both candidates were very careful to say and reassure patients currently on Medicare that they would not be affected by the future changes. Politicians seem to always delay any painful changes until the very last moment. Depending on who wins, “Obamacare” will either see legislative revisions or will start over. In 2013 and 2014 is where we will really experience the changes that have been made and what will be required to pay for health care going forward.

– Douglas W. Jackson, MD, orthopedic surgeon in California; Orthopedics Today, Chief Medical Editor

4:23 p.m.: This election will have a significant impact on the patients I treat on a daily basis. As an orthopedic trauma surgeon, I see people who come into the hospital every day with life-changing injuries. What often surprises me is the despair that my patients express to me, not only because of the injuries they have sustained, but also because they know the huge financial burden the injuries will place on their life and worry that they will be unable to pay their bills.

No matter who wins the election, the future of health care is going to be impacted greatly over the next 4 years. Issues of access, quality, and affordability are all on the line and are issues that both candidates claim they will address, albeit in very different ways. If Mitt Romney is elected and the Affordable Care Act is completely repealed, then I wonder what access to care the uninsured will have, as well as, who will provide care for the large percentage of uninsured patients in the United States. Furthermore, no matter who wins, we truly need a leader who will work to control health care costs as the increase in health care costs is still fundamentally crippling our economy, and on an individual level, crippling the patients who present to my institution with critical injuries.

– A. Alex Jahangir, MD, MMHC, orthopedic surgeon in Tennessee, assistant professor of orthopaedic surgery and rehabilitation, division of orthopaedic trauma, Vanderbilt University Medical Center

4:05 p.m.: Neither candidate did a good job exploring health care-related issues in their campaigns. There was a lack of scholarly discussion as to what options are available, why one plan is better than others, what the features are of the Republican plan and why a compromise is not possible. The people like to know what the common themes are between the two best plans, as well as the areas of disagreement. The debates were a one-line, showbiz type of spectacle that I for one got nauseated listening to and for the most part tried to avoid.

– Ami E. Iskandrian, MD, cardiologist in Alabama; Cardiology Today, Editorial Board member

3:49 p.m.: One of the most important outcome variables to this year’s presidential election will be plans for restructuring health care in the United States. The two candidates offer vastly different plans. If elected, one candidate’s plans will likely result in significant reductions in health care access for individuals receiving Medicaid-associated services. Unfortunately, this may adversely affect many children. As medication costs are a significant component of medical care, access to some useful medicines may be restricted if such health care plans are implemented. Advocates of smaller federal government may significantly limit these programs.

The other candidate’s plans for health care reform have been described and discussed previously, and more is known about these plans for changes and improvements to national health care.

– Edward A. Bell, PharmD, BCPS, professor at Drake University College of Pharmacy; Infectious Diseases in Children, Editorial Board member

3:21 p.m.: The different visions for health care set forth by President Obama and Governor Romney quite clearly highlight the contrasting philosophies each of them (and their parties) envisions for the role of government in society. Does federal government have a broader — and, some might say, moral — responsibility to ensure adequate care for all its citizens (as Obama’s Affordable Care Act seeks to do), or is promoting competition among insurers and maximizing choice for consumers the best way to ensure optimal care for the most people (as Romney believes)? These contrasting principles also extend to federal entitlement programs, which remain at ongoing risk of financial insolvency. Is extending free market principles/consumer choice to Medicare the right idea? What about Medicaid? Should spending be controlled top-down at the federal level, or ultimately decided by individual states? Finally, what will be the true impact of budget reform on federal funding for biomedical research? Can America remain at the forefront if research funding remains static or is cut further?

– Andrew H. Ko, MD, HemOnc Today, Editorial Board member

3:10 p.m.: The first action of the next chief executive of our nation should be to stop implementation of the Affordable Care Act, and to send it back to Congress and to the people of the United States for debate, discussion, and identification of the best way forward.

The reason for doing so is simple enough; the act is a divisive entity that has deepened the partisan divide, and promoted paranoia among a sizable segment of our population. No democracy can afford to disenfranchise a large group of the electorate. The red flag was that the act was passed in the darkness of night, with abbreviated debate, and not a single Republican vote. The president should have been more of statesman and returned the bill to Congress with instructions to come up with a version that was palatable to all sides. On such an important topic, the president should have ensured representation, inclusiveness, and a strong sense of engagement from all parties.

Health care is important, expensive, and threatens the nation’s economic future. This is a matter that touches everyone, and affects every industry. To limit conversation to only the most shrill and radical voices in the arena is to marginalize others who may have valuable perspectives. Specifically, the voices of doctors and patients, two groups who may presumably know something about health care, have been conspicuously absent from this debate, just as they were absent from the truncated debate preceding the stillborn “HillaryCare” attempt to transform health care.

Our health care has many positives. We need a sustainable model going into the future. Americans are a smart, practical people that do not shy away from problems. We need leadership that believes in the people, and draws the considerable talent of our population for solving the problems facing health care. This requires a unified approach, fostered by a true leader with charisma, compassion, and a willingness to listen to all the voices. President Obama made a mistake in isolating and vilifying the Republicans in passing his health care bill; going forward he will pay the price of increased isolationism and partisanship himself. Even if he is re-elected, his next four years are threatened by gridlock, and a Congress that will not cooperate with him. Addressing health care and repealing the Affordable Care Act should be the first order of business.

– B. Sonny Bal, MD, JD, MBA, orthopedic surgeon in Missouri, Orthopedics Today, Editorial Board Member

2:47 p.m.: With the president being re-elected, patients who have been denied insurance because of pre-existing conditions will be able to get health insurance. If Romney is elected, then it will be “same old-same old” with the same number of uninsured now only growing — a circumstance that is a disgrace among industrialized nations.

– Alan H. Morris, MD, orthopedic surgeon in Missouri, Orthopedics Today, Editorial Board Member

2:28 p.m.: Major deleterious effects for lower income patients needing expensive therapies (particularly those with malignant diseases) are likely under a Romney/Ryan administration. Medicaid funds will likely be diminished as financially-strapped states will not be able to maintain current distributions without greater federal support — unlikely in a Ryan-formulated budget. Moreover, a recent perspective by David G. Stevenson, PhD, associate professor of health policy in the department of health care policy at Harvard Medical School, suggests hospice care funding — so critical for many of our patients — is under increasing strain. Stevenson notes that terminally ill patients are likely to confront dwindling hospice financial assistance if current trends continue, especially the trend that for-profit agencies are rapidly replacing nonprofit hospice entities. Under the Affordable Care Act, CMS will have increased authority to address gaming of the previously excellent hospice endeavor. (Stevenson DG. N Engl J Med. 2012;367:1683-1685.) Dismantling of the ACA will subvert any such ameliorating authority — a distressing outcome for us physicians and our terminally-ill patients.

– Harry S. Jacob, MD, FRCPath (Hon), HemOnc Today, Chief Medical Editor

2:15 p.m.: Most of our clients are Medicare recipients who have already seen adverse effects to their care because of the Health Care Reform Act. I believe that if Gov. Romney is elected and repeals “Obamacare” as promised, Medicare will remain a viable insurance benefit into the foreseeable future.

– Joel J. Kempfer, CP, FAAOP, Wisconsin; President, Kempfer Prosthetics Orthotics Inc.

2:03 p.m.: Health care reform is necessary. “Obamacare” was less about reform and cutting costs, but more about universal coverage. There are many undesirable consequences of the law. It should be rejected and true reform with increased coverage should be undertaken.

– Douglas E. Garland, MD, orthopedic surgeon in California, Section Editor, Rehabilitation for Orthopedics Today

1:57 p.m.: The two fundamental problems with U.S. health care are access and expense. The Affordable Care Act improved access but falls short of providing universal care. Most importantly, neither party addressed the tough problem of taming the double-digit cost inflation of health care. The largest remediable areas of cost inflation include:

• administrative costs (due to the current insurance system)
• incentives of fee-for-service system encouraging more procedures, justified or not
• care of chronic disease
• subspecialist costs

[Tackling cost inflation] will require a dramatic restructuring of how we train and reimburse health care practitioners — more physician assistants, nurse practitioners, primary care providers and fewer specialists. This will only happen when the disparities in reimbursement are addressed.

– Jed Gorlin MD, HemOnc Today, Editorial Board member

1:46 p.m.: The next president’s first action needs to be to implement the Mental Health Parity Act. Former US Reps. Jim Ramstad and Patrick Kennedy worked diligently to get this passed through the legislature so that there was not discrimination in payment for mental health services, yet the administration has not signed off on the regulations so that the support can start. Therefore, even though the law was passed, our psychiatric patients are still not receiving appropriate support. I am hopeful that plans for increased insurance coverage will work in a good way for the seriously mentally ill, but their support needs to be at the same level as other illnesses.

– S. Charles Schulz, MD, head of the department of psychiatry, University of Minnesota; Psychiatric Annals, Editorial Board member

1:32 p.m.: (In response to the question: What should be the next U.S. president’s first action regarding health care and/or the Health Care Reform Act?) Anyone’s first knee-jerk response to this question would be “Fix the SGR.” But whether seen through the narrow lens of ophthalmology and other specialties, or the broad lens of the country, the president’s greatest contribution would be to facilitate the development of a responsible path to eventual federal budget neutrality. Continued deficit spending — and worse, expectations that no solution can be found — will soon lead to abrupt and disruptive impacts on ophthalmology. These include double-digit fee reductions, tax increases on providers, the dampening of medical innovation, and ultimately practice cost inflation, which will be very punishing if fees simultaneously fall.

– John Pinto, J. Pinto & Associates, Inc., San Diego; OSN Practice Management, Section Editor

1:02 p.m.: I’m assuming that on Wednesday morning, I’ll be having to get up and get to the office to see my patients in the same manner I have for over 35 years. Yes, there may be some slight changes in the short term, but overall we still have the obligation to get our patients seeing clearly with healthy eyes. As long as insurance companies still exist and control our patient flow, then we’ll have to accommodate to that system.

– Jeffrey Anshel, OD, optometrist in California; Primary Care Optometry News, Editorial Board member  

12:21 p.m.: The first issue confronting the next president is the so-called fiscal cliff, which includes the Sustainable Growth Rate (SGR) formula. Congress has “kicked the can” concerning SGR for the past several years, and each year the threat of draconian physician payment cuts hangs over Medicare providers and beneficiaries. The new president needs to provide some leadership on this urgent matter.

– Kevin J. Corcoran, COE, CPC, FNAO, San Bernardino, Calif.; President, Corcoran Consulting Group

11:47 a.m.: Regardless of who wins the presidential election, if Congress cannot finally work together in the best interests of the American people and avoid the fiscal cliff that looms, the impact on the children and citizens of the US will be devastating. With the current political climate in Washington, Congress is at the worst level of effectiveness and cooperation in my lifetime. They should be held accountable by the American people if they do not work together to move us forward in a positive manner.

– Richard F. Jacobs, MD, pediatrician in Arkansas; Infectious Diseases in Children, Chief Medical Editor

11:18 a.m.: From my perspective, I did not see enough discussion of health care and what changes would occur depending on who the next president is. Romney’s approach — defeat “Obamacare” —was very disappointing but no alternative was suggested except perhaps status quo. Not much discussion from him concerning the Massachusetts program, considering the Obama plan was modeled somewhat after it.

– Joseph R. Bertino, MD, HemOnc Today, Associate Medical Editor

10:30 a.m.: Unfortunately, the cost of health care is increasing at a rate of 0.75% per year, and Medicare expense is already the majority of the 58% of deficit spending attributable to entitlement programs annually. I am concerned that “Obamacare” is going to dramatically increase the cost of medical care despite the “taxes” to increase revenue contained within the plan. Thus, whoever is able to focus on decreasing the deficit is going to have to reduce Medicare expenses, and the easiest way to accomplish this is to decrease reimbursements to physicians and hospitals.

Recent surveys have shown that orthopedists will reduce the number of Medicare patients they see on a weekly basis if reimbursements decrease. Since 10,000 Americans are turning 65 every day, this is going to be a major issue for seniors requiring our expertise.

– Jack M. Bert, MD, orthopedic surgeon in Minnesota, Section Editor, Business of Orthopedics for Orthopedics Today

10 a.m.: I hope the winning party will reach out to the losing party in a genuine effort to compromise, and not just continue the present “do nothing” stalemate. The differences between the candidates seem mostly related to abstract political ideology to me, with both sides having some reasonable practical ideas. Repeal of “Obamacare” is a campaign slogan, not a solution. “Obamacare” needs to be refined and modified, retaining what works and throwing out what doesn’t. Under all circumstances, money in health care will get tighter. I fear more for the indigent than the middle and upper classes. I do believe that mitigation of our escalating health care expenditures is key to the future economic prosperity of our country.

– L. Samuel Wann, MD, cardiologist in Wisconsin; Cardiology Today, Section Editor  

9:30 a.m.: The two candidates have significantly different plans for the Health Care Reform Act and health care reform in general, so the election outcome is important to our patients and our practice. I do not foresee any significant short-term impact, but what private practice in America will be like in 2016 and 2020 will be quite different depending on who is elected president, and of course, the makeup of the Senate and the House of Representatives.

– Richard L. Lindstrom, MD, Ocular Surgery News, Chief Medical Editor

9:15 a.m.: The actual care system changes resulting from the Affordable Care Act health care law are predicted to vary depending on how local entities design and implement their own versions of accountable care organizations (ACOs). The law decentralized many of the design decisions about ACOs and how they will organize the interface between patient-centered health care homes and mental health specialty services, so, for instance, an ACO system in a rural area will likely look quite different than a system in an urban area.

Regardless of what happens with the law after the election, it is safe to assume that change is still coming to our care system because insurers and employers know that the status quo is not financially sustainable.

– Robert J. Hilt, MD, FAAP, Seattle Children's Hospital; Psychiatric Annals, Editorial Board member

 8:45 a.m.: Both candidates and their parties did a poor job of exploring health care issues and what they would do about them. It seems that the Democrats have run away from the Affordable Care Act ever since they passed it. The majority of the Act is a consumer protection bill designed to improve access to health care for everyone, not just the millions of Americans who do not currently have health insurance. I have found that when many individuals I speak with who state they are against the Affordable Care Act are told the specifics of how they will benefit from it - especially changes in insurance coverage for their adult children, limitation then removal of lifetime caps and improved portability - they are surprised and confused. The Democrats have allowed the Republicans to frame the debate in a way that prevents the average person from learning exactly how the changes benefit them and their family.

The Republican response has been dishonest and disingenuous. That millions of Americans fail to acknowledge the abject hypocrisy of Romney on this subject is truly one of the political wonders of our times. Romney and Ryan clearly intend to "blow up" the Act and fundamentally change Medicaid and Medicare. They fail to recognize or acknowledge that these two programs are far more efficient than private insurance, that a far greater proportion of their available funds go to providing care than in the private sector. They have steadfastly refused to provide details on what they intend to do, an incredibly cynical approach that is beneath the type of political discourse we should expect in this country from our leaders. I try to picture our family's 68-year old former nanny who has early dementia trying to deal with the "system" that the Republicans propose and know that it would be a calamity for her and her family. The Republican ticket has cast its arguments in a haze of fear and confusion using slogans and platitudes instead of facts and reason.

As the ultimate safety net for children, Medicaid serves a vital function in our society and cannot simply be "turned down," as the Republicans imply they will do. What they imply they will do would be an unmitigated disaster for children.

– Jeffrey R. Starke, MD, pediatrician in Houston, Infectious Diseases in Children, Editorial Board member

8:15 a.m.: I listened to the debates but I'm not sure I heard any concrete plans about health care. I would have liked to hear how the average American benefits from both parties’ health care plans.

– Tom Karolewski, Supervisor, Orthotics and Prosthetics,  Edward Hines Jr. VA Hospital

8 a.m.: Health care issues started out strong in the campaigns and dwindled as the economy and Benghazi took over.  After Hurricane Sandy hit the East Coast, so many people focused on their survivability in terms of days, not in terms of what the next four years would be like.  Health care could have arisen as an issue again, but it has not so far.  Aftermath health care issues are huge.  Kudos to the health care professionals who rescued many patients affected by the storm!  Encouragement to them for the challenges ahead in caring for hundreds of thousands of people who will suffer physical and psychosocial problems!  Over decades both public health and mental health have been limited in their funding to provide critical services to protect the public and serve those with mental health issues.  These issues will be acute during the next several months as the East Coast restabilizes and begins the long, arduous task of rebuilding communities.  Neither candidate spoke to devastating public health issues and how healthcare services could be provided.  Jobs are important.  So is health care.   

– Patricia S. Yoder-Wise, RN, EdD, NEA-BC, ANEF, FAAN, Editor-in-Chief, The Journal of Continuing Education in Nursing, Lubbock, Texas

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Editor’s Note: The opinions expressed here are those of the physicians and health care professionals invited to participate in this Healio Blog. They do not represent the opinions of the editors and publisher nor can they be construed as an endorsement for either presidential candidate.