All of the Republican presidential hopefuls have expressed their opposition to Barack Obama's Affordable Care Act and are promising to abandon it if elected. Nellie Bristol reports.It may be the area with the most solid agreement among US Republican presidential hopefuls: all are campaigning on promises to repeal or otherwise dismantle the health reform law strongly supported by President Barack Obama and approved in Congress solely on votes from Democrats.As The Lancet went to press, ahead of the New Hampshire primary on Jan 10, six candidates remained in the battle for the party's nomination to take on Obama in this November's elections. They all view the president's Affordable Care Act as too centrally controlled and unsustainable. But opposing the plan has proven more difficult for some candidates than others. Mitt Romney, for example, has had to do some backpedalling to explain why he now opposes the law when, as governor of Massachusetts, he worked with Democrats in 2006 to fashion a similar insurance system in his state. And Newt Gingrich, former Speaker of the House of Representatives, has been criticised for opposing the reform when previously he supported requiring individuals to purchase insurance or face a fee. The provision, known as the individual mandate, is a cornerstone of the Obama plan.But if they don't like the current reform, what do the candidates propose instead? Many advocate state based, market oriented options that create private insurance purchasing arrangements for the uninsured along with tax credits or deductions to encourage coverage. A less centralised approach would take into account local situations and be more manageable and less expensive, they argue. “Different states will experiment with and settle on health care solutions that suit their residents best”, Romney said.While criticising a federal response to improving health coverage, many of the candidates also advocate much tighter control over government funding for health, including for Medicare, the federal programme for elderly and disabled people. Several, including former Utah Governor Jon Huntsman and former US Senator Rick Santorum support a set government contribution to Medicare beneficiaries to buy private coverage, a plan critics say would reduce benefits under the programme. Many of the candidates also support increased state control over the joint federal/state Medicaid programme, which provides health care for low-income families.In other health positions, Gingrich supports use of a “personalised intelligent health system” that would allow individuals timely access to their health information and help them gain control over their own care. Ron Paul, a physician and congressman from Texas, cites privacy concerns in supporting provisions allowing physicians and patients to opt out of federal electronic medical records systems. The most extreme government minimalist of all the candidates, Paul also has argued that Medicare, Medicaid, and other government programmes are unconstitutional and create undue dependence. “Why exactly should Americans be required by force of taxation to fund retirement or medical care for senior citizens, especially senior citizens who are comfortable financially?” Paul said in a weekly telephone message to supporters in November, 2010.Although little debate has occurred on science issues, several candidates are on record as opposing embryonic stem cell research. Gingrich, for example, a strong supporter of research into diseases and conditions like Alzheimer's, autism, and Parkinson's, said in response to a survey on science policy, “I strongly support adult stem cell research. I will oppose at every turn any process of destroying embryos”. Also in the survey, done by the science advocacy group Research!America, Gingrich, the only Republican respondent so far, said he supports preventive health measures to fight chronic diseases and called for structural reform of the Food and Drug Administration (FDA). “Americans deserve a fair and competent regulatory regime that emphasizes both consumer safety and ensures that life-saving breakthroughs get from laboratories to patients as quickly as possible”, he said. “Unfortunately, the current FDA falls well short of this expectation, and its stagnant, bureaucratic and byzantine regulatory guidelines are scaring off new investment and driving innovators overseas.”Global health also has not received much attention in the campaign so far, although several candidates have positions on foreign aid overall. Perry, for example, said he would directly tie aid to a country's support for the USA. Paul has called for discontinuation of all foreign aid. Santorum, however, said on a news programme in November, 2011, that those criticising foreign aid were “pandering to an anti-foreign aid element out there”. He calls for an expanded commitment to humanitarian aid, particularly for Africa. “China and Islam are competing for the hearts and minds of much of Africa, and we cannot turn our back from the investment and commitments we have made”, he said in campaign documents. All of the Republican presidential hopefuls have expressed their opposition to Barack Obama's Affordable Care Act and are promising to abandon it if elected. Nellie Bristol reports. It may be the area with the most solid agreement among US Republican presidential hopefuls: all are campaigning on promises to repeal or otherwise dismantle the health reform law strongly supported by President Barack Obama and approved in Congress solely on votes from Democrats. As The Lancet went to press, ahead of the New Hampshire primary on Jan 10, six candidates remained in the battle for the party's nomination to take on Obama in this November's elections. They all view the president's Affordable Care Act as too centrally controlled and unsustainable. But opposing the plan has proven more difficult for some candidates than others. Mitt Romney, for example, has had to do some backpedalling to explain why he now opposes the law when, as governor of Massachusetts, he worked with Democrats in 2006 to fashion a similar insurance system in his state. And Newt Gingrich, former Speaker of the House of Representatives, has been criticised for opposing the reform when previously he supported requiring individuals to purchase insurance or face a fee. The provision, known as the individual mandate, is a cornerstone of the Obama plan. But if they don't like the current reform, what do the candidates propose instead? Many advocate state based, market oriented options that create private insurance purchasing arrangements for the uninsured along with tax credits or deductions to encourage coverage. A less centralised approach would take into account local situations and be more manageable and less expensive, they argue. “Different states will experiment with and settle on health care solutions that suit their residents best”, Romney said. While criticising a federal response to improving health coverage, many of the candidates also advocate much tighter control over government funding for health, including for Medicare, the federal programme for elderly and disabled people. Several, including former Utah Governor Jon Huntsman and former US Senator Rick Santorum support a set government contribution to Medicare beneficiaries to buy private coverage, a plan critics say would reduce benefits under the programme. Many of the candidates also support increased state control over the joint federal/state Medicaid programme, which provides health care for low-income families. In other health positions, Gingrich supports use of a “personalised intelligent health system” that would allow individuals timely access to their health information and help them gain control over their own care. Ron Paul, a physician and congressman from Texas, cites privacy concerns in supporting provisions allowing physicians and patients to opt out of federal electronic medical records systems. The most extreme government minimalist of all the candidates, Paul also has argued that Medicare, Medicaid, and other government programmes are unconstitutional and create undue dependence. “Why exactly should Americans be required by force of taxation to fund retirement or medical care for senior citizens, especially senior citizens who are comfortable financially?” Paul said in a weekly telephone message to supporters in November, 2010. Although little debate has occurred on science issues, several candidates are on record as opposing embryonic stem cell research. Gingrich, for example, a strong supporter of research into diseases and conditions like Alzheimer's, autism, and Parkinson's, said in response to a survey on science policy, “I strongly support adult stem cell research. I will oppose at every turn any process of destroying embryos”. Also in the survey, done by the science advocacy group Research!America, Gingrich, the only Republican respondent so far, said he supports preventive health measures to fight chronic diseases and called for structural reform of the Food and Drug Administration (FDA). “Americans deserve a fair and competent regulatory regime that emphasizes both consumer safety and ensures that life-saving breakthroughs get from laboratories to patients as quickly as possible”, he said. “Unfortunately, the current FDA falls well short of this expectation, and its stagnant, bureaucratic and byzantine regulatory guidelines are scaring off new investment and driving innovators overseas.” Global health also has not received much attention in the campaign so far, although several candidates have positions on foreign aid overall. Perry, for example, said he would directly tie aid to a country's support for the USA. Paul has called for discontinuation of all foreign aid. Santorum, however, said on a news programme in November, 2011, that those criticising foreign aid were “pandering to an anti-foreign aid element out there”. He calls for an expanded commitment to humanitarian aid, particularly for Africa. “China and Islam are competing for the hearts and minds of much of Africa, and we cannot turn our back from the investment and commitments we have made”, he said in campaign documents.