If there was one area where Mitt Romney and President Obama sometimes seemed to inhabit parallel universes at their debate on Wednesday night — with separate sets of assumptions, beliefs and even facts — it was on the question of health care and government’s role in providing it.

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Mr. Romney sharply criticized Mr. Obama’s health care law, falsely suggesting that it would allow the federal government to “take over health care.” He painted a vision of a reshaped Medicare system in which the elderly would get fixed amounts of money to buy private or public plans, fostering competition. And he called for capping federal Medicaid spending and sending it to the states to decide how to spend it.

Mr. Obama noted the similarities between his health care law and the one Mr. Romney signed as governor of Massachusetts, saying: “It wasn’t a government takeover of health care. It was the largest expansion of private insurance.”

He warned that under Mr. Romney’s Medicare plan, private insurers would pick the healthiest seniors, endangering the public health plan by leaving it with the sickest, most-expensive-to-cover patients. And he described Mr. Romney’s Medicaid cuts as “a big problem” for “a family who’s got an autistic kid and is depending on that Medicaid.”



Two of their sharpest divisions came over how to insure people who are already sick, and what Medicaid should look like.

Mr. Obama said that if Mr. Romney repeals his health care law, insurers would no longer be required to provide coverage to people with pre-existing medical problems. Mr. Romney countered that “pre-existing conditions are covered under my plan.”

Mr. Romney made a similar claim in an appearance last month on NBC’s “Meet the Press.” At the time, he said, “I’m not getting rid of all of health care reform. Of course, there are a number of things that I like in health care reform that I’m going to put in place. One is to make sure that those with pre-existing conditions can get coverage.”



But Mr. Romney’s aides later clarified that he would only explicitly guarantee insurance for people with pre-existing conditions if they have maintained coverage with no significant lapses. That could exclude millions of Americans with conditions like cancer, heart disease and asthma.

Breaks in coverage are common. A recent report by the Commonwealth Fund found that 89 million Americans went without health insurance for at least one month in the period from 2004 to 2007, perhaps because they had lost jobs, been divorced or lost eligibility for a public insurance program.

For people who have not been continuously insured, Mr. Romney says many of them could get coverage through health plans known as high-risk pools. Many states have such pools, which generally operate at a loss. And the federal government is running a high-risk pool, as a temporary measure under the new health care law, in more than 20 states.

But Mr. Romney has not provided details, like whether or how he would regulate premiums or subsidize the high cost of coverage in a high-risk pool.

A 1996 federal law already limits the ability of health plans to exclude coverage for pre-existing conditions. But under that law, consumers may lose some of their rights if, for example, they do not buy an individual insurance policy within 63 days of losing group coverage. Mr. Obama said during the debate that Mr. Romney’s plan only duplicates what is “already the law, and that doesn’t help the millions of people out there with pre-existing conditions.”

The two men also differed over their vision for Medicaid, the jointly administered state-federal program that provides health care to nearly 60 million low-income individuals, including children and families, people with disabilities and seniors who need long-term care.

The federal government currently provides matching money to states based on how much they spend, so states with more generous benefits qualify for more federal dollars. Mr. Romney wants to cap the growth of Medicaid spending and let states decide how to spend it.

“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,” he said at the debate. “And then you’re going to manage your care for your poor in the way you think best.”

In a speech last November, Mr. Romney estimated that such a cap would save the federal government $100 billion a year.

Mr. Obama criticized the proposal at the debate, saying “Governor Romney 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.”

He was relying on a study conducted by the Urban Institute, a nonpartisan research group, for the Kaiser Commission on Medicaid and the Uninsured. The study examined a 2011 proposal by Representative Paul D. Ryan, Mr. Romney’s running mate, to transform Medicaid in essentially the same way Mr. Romney has called for.

Mr. Ryan’s plan called for cutting federal spending on Medicaid by $810 billion over 10 years by turning Medicaid into a block-grant program. According to the Urban Institute study, federal spending on Medicaid under the Ryan plan would be 33.9 percent less over 10 years than it is projected to be under Mr. Obama’s health care law, which would enroll millions of additional people in Medicaid.

Under a block-grant program like the one Mr. Romney has proposed, each state would get a fixed payment and more leeway to decide eligibility and benefits. (Currently, the federal government sets minimum requirements, like covering all children under the poverty level, which some states surpass. It also provides unlimited matching funds.)

Mr. Romney says, correctly, that the program’s soaring costs are swallowing an ever-larger chunk of state budgets. States have generally not been allowed to cut Medicaid eligibility since the passage of Mr. Obama’s health care law in 2010, but many have slashed optional benefits and payments to doctors and hospitals instead. Mr. Obama wants to vastly expand the program, with the federal government paying almost all of the costs for the millions who would become eligible through the expansion. During the debate, Mr. Romney stressed that his proposal would free up states to make their own decisions.

“One of the magnificent things about this country is the whole idea that states are the laboratories of democracy,” he said. “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.”

But critics of the block grant plan say it would shrink the medical safety net for the poorest Americans. The Urban Institute study estimated that under Mr. Ryan’s proposal millions of people could lose Medicaid coverage by 2021.

And the two men sparred repeatedly over Medicare. Mr. Romney, who has declined to give specifics about how much money he would propose giving future beneficiaries to buy coverage, denied that his plan would raise their out-of-pocket costs, saying it would foster competition. But Mr. Obama noted that Medicare has lower administrative costs than private insurance, and that private insurers strive to make a profit.

“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,” he said.

Mr. Romney took pains to note that his plan would not take effect for a decade. “If you’re 60 or around 60 or older, you don’t need to listen any further,” he said at one point.

Mr. Obama looked at the other side of that equation. “If you’re 54 or 55, you might want to listen,” he said, “because this — this will affect you.”