Even though their visions for private and public coverage differ in many ways, the overarching distinction between the candidates is how they prioritize coverage expansion vs reduced federal spending on health care. As such, it is the focus of the ACA, which will substantially increase the numbers of insured through an expansion of Medicaid and the (subsidized) private health insurance market. Notwithstanding his pledge to reverse the ACA and spend more on Medicare in the near term, Romney's proposals generally favor spending reductions, withdrawing federal support for private insurance expansion, drastically reducing Medicaid spending, eliminating Medicare coverage for 65- and 66-year-olds, and restructuring Medicare into a defined contribution program for those currently younger than 55 years. These are major differences and will have enormous effects on all facets of the health system and the number of uninsured, as well as federal costs. On health policy, as well as other areas, voters have a real choice in November.