The chief question candidates running for office this election cycle must answer is how to improve the economy. How to reform the health care system and expand access to coverage follow closely behind.

Just seven months ago, Democrats in Washington passed the most ambitious health care reform package in a generation. If Republicans in the capitol don't chip away at the law before it's fully implemented, which would disappoint roughly 60 percent of Americans who want the law left alone or expanded, roughly 1.3 million uninsured Illinoisans will gain affordable coverage by the end of the decade. Another 2.5 million residents under 65 who have a pre-existing condition won't have to fear being denied insurance, either.

At the state level, Medicaid is taking up an increasing share of the budget. Falling tax receipts are forcing lawmakers to make tough decisions about how many human service programs they can administer. And state legislators were given wide latitude to decide how to implement key provisions of the new federal law.

That power makes this year's gubernatorial election extremely important. Will Illinois' new chief executive embrace health care reform and the basic ideas it promotes or reject it outright and chart a new course for health care delivery? If GOP gubernatorial nominee Bill Brady wins next week, expect the latter. Here's an overview of his broad positions on the topic:

The Health Care Reform Law

Make no mistake about it: Bill Brady is no fan of the Obama administration's health care bill. Indeed, he voted against (PDF) a bill that established the Health Care Justice Implementation Task Force, which will monitor the execution of federal health care law and make recommendations for any additional reforms needed to ensure affordable health care in Illinois.

This vote should worry reformers intent on making the state's health insurance exchange progressive. The success of the federal initiative depends on the creation of a strong exchange, a government-regulated clearinghouse where those who aren't offered a health care plan through work can purchase insurance with the help of government subsidies and tax credits. Health care advocates like Illinois PIRG and the Campaign for Better Health Care want leaders of the state's exchange to actively negotiate prices and benefit packages with insurance companies seeking to join the clearinghouse.

As CBHC's Jim Duffet told us this summer, Illinois should require insurers to offer additional benefits on top of those mandated by Congress so consumers aren't stuck with what he calls "skin and bones" benefit packages.

Some conservatives have argued that the exchange should be open to any insurance company that wants to participate. Let the free market set prices and benefit levels, they counter. (Michael Brady, on behalf of Blue Cross/Blue Shield of Illinois, made the same point at the state task force's first public meeting last month.) That approach, however, takes away the state's direct ability to set common standards and encourage delivery reforms; insurance companies may be willing to change how they do business quite dramatically if the state can promise them access to hundreds of thousands of potential new clients. Sen. Brady, according to an interview with Duffett by the AP, is "consistently on the side of insurance companies." The Republican, in other words, might push for a neutered exchange.

The GOP nominee seems a bit confused about the other major component of health care reform impacting state government -- the expansion of Medicaid. In an interview with the News-Tribune this spring, Brady claimed that the Democratic health care reform package will add "up to $6 billion" in additional costs for the state. That's just bananas. The federal government is picking up the bulk of the costs through the first decade, when Brady would be in office. Indeed, if roughly 900,000 Illinois residents enrolled in Medicaid by 2019, 700,000 of whom were previously uninsured, the state would have to spend an additional $2.5 billion over five years. That's nothing to sneeze at. But it will allow the state to insure almost 70 percent of working poor adults who lack health care coverage for just about $40 per person annually. That's an amazing deal. And the Republican offers no plausible alternative to promote a similar level of coverage. (Health care only takes up four paragraphs on his campaign site.)

Medicaid

Speaking of Medicaid, Brady consistently talks on the stump about the state's public health program for the poor. Earlier this year, he went so far as to call it "one of the worst run Medicaid systems ... in the country." Watch it (the full interview is available here):

Rooting out "waste, fraud, and abuse" and enrolling all patients in private managed care programs, he says, could save approximately $1.2 billion to $1.8 billion annually.

Illinois' Medicaid program is not perfect; providers get stiffed and the system, like the rest of the health care industry, is subject to rising costs. It'd be nice, though, if Brady once acknowledged that the major reason Illinois spends a lot on its public health program -- $15.2 billion this fiscal year, $8.4 billion of which comes from the federal government -- is because demand is extremely high. Over the past decade, enrollment doubled. Between December 2007 and December 2009, almost 200,000 people qualified. When Illinois losses jobs, the safety net must expand.

On the issue of fraud, Brady points to the state's eligibility verification standards. "The Medicaid program under Governor Quinn allows people like Governor Quinn to walk in and receive an eligibility card," he said during a debate last week. "We don’t verify eligibility in the Medicaid program." Listen:

While there are surely some undeserving taxpayers receiving Medicaid (or All Kids) care, the Illinois Department of Healthcare and Family Services does review eligibility using pay stubs annually. The General Assembly also passed several state laws this year, with bipartisan support, that increased transparency and authorized outside audits of the system. So work is being done on this front.

Brady's support for private managed care, meanwhile, would eviscerate two public programs that employ "managed care" principles, Illinois Health Connect and Your Healthcare Plus, and saved roughly $440 million last year. And he's not made clear how his administration would better protect Illinois patients who previously suffered from the history of "failures, abuses, and outright fraud" perpetrated by private managed care organizations here. That's a legitimate question that needs to be answered.

Gov. Pat Quinn, for what it's worth, has launched a private managed care pilot program for approximately 38,000 elderly and disabled Medicaid beneficiaries from Northeastern Illinois. "We would hate to see the state gamble on capitated care for all, or even most, Medicaid patients," the Sun-Times editorial board wrote in February, "at the expense of programs that already work."

Medical Malpractice

Even though malpractice costs make up only a small percentage (2.4 percent) of national health care expenditures, the threat of lawsuits decreases the quality of care and the number of physicians in the field. That makes it a problem worth tackling.

Here in Illinois, the General Assembly passed a relatively stringent package of malpractice reforms in 2005 that capped non-economic damages at $500,000 for physicians and $1 million for hospitals; Brady voted in favor of the legislation. This year, the Illinois Supreme Court ruled (for the third time) that the caps were unconstitutional. The court -- including Justice Thomas Kilbride, now fighting for his retention -- said the law violated the state's separation-of-powers clause by giving lawmakers the ability to interfere with a jury's right to determine damages.

If Brady was serious about protecting doctors and hospitals from insurance premium spikes, he'd put aside the issue of hard caps (at least for the time being) and work with Democrats to reinstate a series of alterations to the Illinois Insurance Code that were included in the 2005 bill but were also tossed out with the broader package. State regulators have said those rules were key drivers behind the recent dip in premiums. (The Department of Insurance even urged insurers to follow the guidelines voluntarily.)

State Sen. Kwame Raoul (D-Chicago) tried to revive those rules this session, but to no avail. It'd be nice to see the GOP standard-bearer reach across the aisle when the Assembly returns.

Abortion

The state senator assured the Daily Herald during his endorsement interview that he had no social agenda for the Land of Lincoln. He did make one exception: "Parental notification [of abortions] is the only thing we think immediately on the books that needs to be done."

Brady is referring to Illinois' parental notification law, which requires doctors to notify a teenage girl's guardian 48 hours prior to performing an abortion. The law has been caught up in court for years. A Cook County judge has lifted the temporary restraining order on the law, but cautioned that doesn't mean it will (or should) go into effect right away.

Given his broad opposition to abortion, even in the cases of rape and incest, we can likely expect Brady to veto any legislation that removes barriers to reproductive care, like the stalled Reproductive Health and Access Act.

State Budget

It's no secret that Illinois has a massive budget deficit with which to contend. Brady has said he can close the entire gap with cuts alone. This will require reductions in state Medicaid funding, which could then endanger federal funding and slow down the state's economic recovery. It also might mean further erosion of the state's tattered safety net. Soon-to-be mothers in Illinois, for example, are poised to see important expectant care services disappear at a time when they are most needed. If Brady assumes the top office in the state, we might see more horror stories like that in the coming months.