The signature achievement of President Barack Obamas term could be out the door if Mitt Romney wins in November, but the debate over the future of health care in America will continue and possibly dominate the next term no matter who gets elected.

The candidates competing visions could scarcely be more dissimilar, even though Obamas Affordable Care Act was closely modeled after the health care plan Romney signed into law while governor of Massachusetts.

If President Barack Obama wins re-election, he can be expected to fully phase in the 2010 law which is designed to extend health coverage to millions of Americans without insurance. And he likely will retain the basic structures of Medicare and Medicaid, the Great Society programs that provide health coverage to the elderly and the poor respectively.

Should Romney win the presidency, count him on him to try to repeal the 2010 law which has earned the nickname Obamacare, while launching a sweeping transformation of Medicare and Medicaid.

The competing roads on dealing with the millions of Americans without health insurance while simultaneously trying to restrain the growth of federal health programs has been a dominant dispute in a testy presidential race that is sure to get testier in the coming weeks.

During the first presidential debate this month in Denver, Obama complained that Romney wants to replace the 2010 health law but he hasnt described what exactly wed replace it with other than saying were going to leave it to the states.

By contrast, Romney argues that the health law has discouraged small companies from hiring people. During the same debate, he assailed Obama for spending his energy and passion during his first two years in office fighting for Obamacare instead of fighting for jobs for the American people. It has killed jobs.

No matter who wins the election, the grim reality of Americas health care system is not going to vanish. Even under Obamas health law, as many as 20 million Americans will still lack health coverage. If Romney either persuades Congress to repeal the law or allows states to ignore it, some predict that the number of uninsured people could climb to nearly 50 million.

In addition, the crushing costs borne by the federal government to finance Medicare and Medicaid only will grow more burdensome. The non-partisan Congressional Budget Office projects that combined federal spending on Medicare and Medicaid will increase from $822 billion this year to more than $1.6 trillion by 2022.

By contrast, the CBO calculates that by 2022, the government will spend just $647 billion on domestic discretionary programs such as housing, education, and transportation. In essence, the government will be devoting more financial resources to the elderly as opposed to the young.

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Health care future hinges on presidential vote