What People Are Saying About the Republicans Health Care Plan 

The Republican bill hikes premiums by 30% for people with pre-existing conditions if for any reason – such as losing a job – they don’t have coverage for 63 days.

The Republican bill pushes people into high-deductible insurance plans and ends the ACA program that limits out-of-pocket costs to many working families.

The Republican bill ends Medicaid expansion and slashes state funding for the regular Medicaid program by radically changing the way Medicaid is funded. States will be forced to end coverage and eliminate health care services for seniors, people with disabilities, children and working families.

The Republican bill gives huge tax cuts to the wealthiest Americans and to drug, insurance and medical-device companies – it even has a special tax break for health insurance CEOs.

Key provisions:

o Ends the ACA’s tax credits, which were based on income, starting in 2020 and replaces them with tax credits that only go up with age.
o Tax credits are reduced to $2,000 for people under 30 to $4,000 for people over 60.

o Phases out the tax credits for incomes above $75,000.

o Tax credits are not adjusted by local cost of living.

o At the same time, allows insurance companies to charge seniors up to 5 times as much as young people – current law is 3 times. Most people will get much lower tax credits and so have to pay more themselves for coverage – with moderate-income families, older people, and people who live in high medical cost areas seeing the biggest increases. 

o Immediately eliminates the ACA’s requirement that individuals have insurance coverage and that employers with more than 50 employees pay for coverage.

o Ending the individual mandate, combined with keeping coverage for pre-existing conditions and lowering tax credits, will start an insurance market death spiral. People who are the sickest will scrape to find a way to buy coverage while others drop out, leading to higher premiums and more people dropping out.
Ends Medicaid expansion and cuts coverage for children and adults in Medicaid.

o Ends Medicaid expansion beginning in 2020, with some transition for people already enrolled.

o Only requires states to cover children in Medicaid who are under the poverty level, reducing the requirement from 133% of the poverty level.

o Ends federal funding for adults in Medicaid who are over 133% of poverty.

Replaces Medicaid’s funding of actual health spending bycapping at a cost per-person, starting in October 2019.

o Instead of states getting a fixed percentage of payments from the federal government (which varies by state), the federal government would cap the amount that it pays per person at the medical CPI.

o Capping Medicaid will result in hundreds of billions of dollars in cuts to states.

o In a public health crisis – the opioid crisis, Zika, etc. – the federal government will not increase funding for state Medicaid programs.
Pushes people into high-deductible health plans, through several provisions.

o Allows insurance companies to sell catastrophic plans, ending the requirement that plans cover a set percentage of medical costs – the ACA’s platinum, gold, silver and bronze plans.

o Ends the ACA’s plan that limits out of pocket costs for people with moderate incomes.

o Increases tax benefits of health savings accounts, which are usually high deductible plans that only work if you are rich enough to save money out of your paycheck.
Hikes health care costs for people with pre-existing conditions.

o Insurance companies must charge anyone who has not been insured for 63 days a 30% surcharge on their premiums.

o Sets up a “Patient and state stability fund,” which can fund state high-risk pools, for people who need costly medical care. The 35-year history of states attempting high-risk pools resulted in high-premiums, high-deductibles and long-waiting lists.
Huge tax breaks – $525 billion over 10 years – for the wealthy and for drug, insurance and medical device corporations.

o Ends the ACA’s taxes on unearned income for people with high incomes. The top 0.1% of households—those with income of at least $3.7 million a year—would receive a tax cut of about $197,000 in 2017, on average.

o Ends the ACA’s taxes on insurance, drug and medical device corporations.

o Even ends an ACA provision that limited insurance companies from writing off high executive salaries.

o Defunds Planned Parenthood.

the republican health plan

​​​​​​​​​Now that President Trump has been clearer about his Infrastructure plans, I want to send around a note about his initiative, his objectives, and key features.  I think it is important to have a sense of it, as little reporting is happening. Last week was Infrastructure  eek for President Trump. He gave two main speeches and the White House released an important brief plan.  On Wednesday, the president spoke about inland waterways and rural infrastructure in Cincinnati.  Later in the week he convened meetings with public officials.  And, on Friday, he talked about streamlining the environmental and regulatory review process at the U.S. Department of Transportation.  President Trump also devoted a YouTube Address to infrastructure.President Trump is now unfolding his Infrastructure plan.  For the most part, the week received little attention given other political events, but the White House can walk and chew gum.

Public-Private-Partnerships are the cornerstone of his plan. Before jumping in, it is important to know what President Trump is talking about when he speaks about infrastructure.  It includes the usual suspects:  transportation, water, and broadband.  However, importantly he also includes so-called Social Infrastructure:  schools, colleges, universities and veterans hospitals.  Also, President Trump includes oil pipelines.  In fact, we will be hearing much more from him about cutting through red tape expeditiously with reference to the Keystone Pipeline and the Dakota project.  President Trump speaks frequently about how he understand the challenges facing infrastructure from his time as a developer, for example tied to regulatory hurdles.  This is no doubt the case. Importantly though, infrastructure investment has played a role in the President's success as a developer. In the Art of a Deal, Mr. Trump's best-selling book recounting his ascendency as a businessman, he talks about one of his most important deals:  the redevelopment of the Commodore Hotel in Midtown.  The Commodore was a run down hotel which Trump took an interest in.  It was near Grand Central Station, which is decidedly not what it is today.  Trump would go look at the hotel in the mornings and end-of-work and see commuters from Westchester and Connecticut streaming through the neighborhood.  He thought to himself that this commuter traffic was a harbinger for a bright future for the Commodore. Trump then embarked on a long dramatic process to acquire the property and secure a series of tax incentives from NYC. It turned out that this investment in the neighborhood and in Grand Central Station paid off in spades.  The Commodore is now the Grand Hyatt.  So, a clear case for transit-oriented development. So, this is a president who understands not only how government can get in the way of projects, but also how infrastructure creates wealth. The President ran for office on making an investment in infrastructure.  For most of his campaign the approach was to buttress traditional financing mechanisms.  However, in the Fall, right before the election, one of his advisers released an infrastructure plan which contrasted candidate Trump's approach with Secretary Clinton's. The cornerstone of that plan was public-private partnerships.  It sought to use tax credits to stimulate private investment and in doing so produce a high single digit returns for investors.Since coming to office, the president's views have evolved although partnerships remain the cornerstone of his approach.ere is a brief rundown of the President's approach to infrastructure investment--  

* $200 billion over ten years brings $800 billion of outside money - from states, cities and private sector to the table  Lower the average permitting from ten-years to two-years Harness private sector - 'innovation and capital' - to drive the infrastructure program
* Invest $15 billion in transformative projects* Spend $25 billion on rural projectsInvest $100 billion in localized projects Implement skills-based apprenticeships which we will learn more about this week. It may be useful to give a little on how the President approaches infrastructure spending.  Then, we can turn to some of the programmatic initiatives he has in mind. For President Trump, it is all about leverage.  Right now, he sees government as spending too much money in a not-so-targeted way.  In his view, the federal government should help catalyze projects but not be the main driver or financier of them. When Mr. Trump talks about leveraging federal dollars, he does not simply mean using federal money to attract outside private capital.  Instead, he is talking about using federal money in a more targeted judicious way.  That money should be used to bring in state, city, and private capital. So when the federal government spends $200 billion over the next ten years to bring $800 billion of additional outside money to the tale, he is including states, cities and private contributions as outside capital. This fact is significant for two reasons. 

First, his plan is not just a public-private partnership one. The White House is now turning to cities and states and telling them to bring ripe projects to them.  They must be 30-60-90 days from RFQ and the city or state must agree to pony up the bulk of the money for the project. This is already starting to happen.  Although we will eagerly await infrastructure legislation and, no doubt, bemoan its tardiness, plenty will happen between today and legislation.  It already is.  We will see, increasingly, focus on what the Administration is doing without legislation. The infrastructure plan envisages what is called asset recycling.  Asset recycling is simply a deal where the private sector advances the government a large lump sum payment for the infrastructure asset in exchange for the right to charge user fees for the upgrade, operation and maintenance of the asset.  Importantly, the government can use that upfront lump sum payment to pay for other projects in its capital program.  The President makes a number of concrete proposals for how specifically federal leveraging money will be spent.  He will increase the capitalization of what are called TIFIA and WIFIA.  These are loan programs for transportation and water projects, public and private ones.  In fact, most of the water ones will end up being for public projects. The President was in Cincinnati talking about Thomas Jefferson, NY Governor Dewitt Clinton, and the Erie Canal.  He was speaking about making investments into our internal waterways in America's Heartland to help bring goods to market, move steel, and assist our agricultural economy.  There's some stuff about giving good bonds to the public and private sector. For urban projects, the President seeks to promote the use of congestion charging.  A new source of revenue for investors. Importantly, the president wants to permit the tolling of the interstate highway system.  This could unlock tremendous capital. Interestingly, the administration is seriously talking about creating a federal revolving fund.  It would focus on creating new capital assets rather than simply the operation and maintenance of existing ones.  It would exist in parallel to the appropriations process.  The aim of the fund would be to help pursue projects with strong return-on-investment potential. Beyond these proposals, the President feels very strongly that tremendous amounts of money can be saved by cutting down on approval processes.  The previous administration made efforts to do so as well; however, this administration is seeking much more sweeping change. It will conduct pilot programs, greater accountability of our federal agencies, create a single point agency to lead an application through the system, devolve regulatory decision making to cities and states, and decrease litigation.  There is now a council put in place to guide applications through the process. Overall, the Trump Administration takes the position that the federal government is in fact a junior partner in most infrastructure projects.  For them, why should projects be subject to onerous federal regulation.  Two things then-- We will see projects getting done while we wait for legislation This isn't a Wall Street plan, although private investment is a cornerstone  First come, first serve for projects. 

Michael Likosky, Michael Likosky is a principal and head of Infrastructure at 32 Advisors. He holds a JD and DPhil (Oxford Law). Michael is an expert on infrastructure, oil and gas, mining, free zones, human rights, foreign investment, and high technology growth strategies.






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