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1. Tom Gibney, CPA/MBA
Chief Financial Officer
Montefiore St. Luke’s Cornwall
A SNAPSHOT OF CURRENT
PROPOSALS

3. HEALTHCARE

4. 1. Healthcare (74%)
2. Economy (71%)
3. National Security (71%)
No Other Issue Topped 70%

5. REPUBLICANS:
DEMOCRATS:

6. OUTLINE
1. CAN WE AFFORD WHAT WE
HAVE NOW?
2. KEY PROPOSALS
3. WHERE DO THE
CANDIDATES STAND?

7. ($ In Trillions)
Healthcare $1.5
SS 1.0
Defense 0.7
Interest 0.4
Other 0.8
Total $4.4

8. ($ In Trillions)
Income Taxes $1.7
Payroll Taxes 1.2
Corp. Taxes 0.2
Other 0.3
Total $3.4

9. ($ In Trillions)
Income $3.4
Expenses (4.4)
Total ($1.0)

10. ($ In Trillions)
Dec. 2018 $22.0
2019 Deficit 1.0
Dec. 2019 $23.0

11. Debt $23.0
GDP $21.5
Debt as % of GDP 107%
Healthy economy <75%

12. • Aging Population
> 65 in 2016 (49M – 15%)
> 65 in 2030 (73M – 21%)

13. • Medicaid Expansion
• 2013 – 57M
• 2019 – 72M
• 14 More States to Go

14. • Declining Birth Rate
• Shrinking Future Tax Base
• No Clear Path on Immigration
• Interest And More Interest

15. Debt @ 12/31/19 $23.0
Deficits 2020-2029 12.2*
Debt @12/31/29 $35.2
*Maybe we should tackle this first?

16. Debt @ 12/31/29 $35.2
GDP (2.5%) 27.5
Debt as % of GDP 128%

17. • Medicare for All Act of 2019
- S.1129 (Sen. Bernie Sanders, I-VT.)
• Medicare for All Act of 2019
- H.R. 1384 (Rep. Pramila Jayapal,
D-Wash.)

18. • Keeping Health Ins. Affordable Act of
2019
- S.3 (Ben Cardin, D-MD)
• Choose Medicare Act
- S.1261 (Jeff Merkley, D-OR)
- H.R. 2463 (Cedric Richmond, D-LA)

19. • Medicare – X Choice Act of 2019
- S.981 (Michael Bennet, D-CO &
Tim Kaine, D-VA)
- H.R. 2000 (Antonio Delgado, D-NY)
• The Choice Act
- S. 1033 (Sheldon Whitehouse, D-RI)
- H.R. 2085 (Jan Schakowsky, D-IL)

20. • Medicare At 50 Act
- S. 470 (Debbie Stabenow, D-MI)
• Medicare Buy-In and Healthcare
Stabilization Act of 2019
- H.R. 1346 (Brian Higgins, D-NY)

21. • Medicare for America Act of 2019
- H.R. 2452 (Rosa DeLauro, D-CT &
Jan Schakowsky, D-IL)

22. • State Public Option Act
- S. 489 (Brian Schatz, D-HI)
- H.R. 1277 (Ben Ray Lujan, D-NM)

24. Sec. 102 (a):
- “Every individual who is a Resident
of the U.S. …”
Sec. 102 (b):
- “The Secretary may make eligible
other Individuals not described in
(a)…”

25.  No Deductibles
 No Co-Insurance
 No Co-Payments
Exceptions:
- Non-Preventive Drugs
($200 Annual Max)

26. - IP & OP Hospital Care
- Reproductive, Maternity, & Newborn Care
- ER & Ambulatory Services
- Primary & Preventive Services
- Lab & Diagnostic Services
- Prescription Drugs & Medical Devices
- Dental
- Audiology
- Vision

27. “… The Secretary shall establish,
by regulation, fee schedules that
establish payment amounts for
benefits under this Act in a
manner consistent with processes
for determining payments for
items and services under Title
XVIII of the Social Security Act…

28. Unlawful for:
- Private Health Insurer to sell
coverage that duplicates benefits
under this Act
- Employer to provide benefits that
duplicate benefits under this Act

29. ($ IN TRILLIONS)
2019
SQ
2029
SQ
2029
M4A
Healthcare $1.5 $2.5 $6.2
SS 1.0 1.8 1.8
Defense 0.7 0.9 0.9
Interest 0.4 1.0 1.0
Other 0.8 0.9 0.9
Total $4.4 $7.1 $10.8

30. ($ IN TRILLIONS)
2019
SQ
2029
SQ
2029
M4A
Inc. Taxes $1.7 $3.0 $5.0
PR Taxes 1.2 1.8 3.0
Corp. Taxes 0.2 0.4 0.7
Other 0.3 0.5 0.7
Total $3.4 $5.7 $9.4

31. Eligibility:
 US Residents, Ages 50 – 64
Benefits:
 Parts A, B & D
 Medicare cost-sharing standards,
subject to ACA financial
assistance eligibility

32. Enrollment Process:
Likely ACA marketplace
procedures and rules
Have option to enroll in FFS or
MA (higher premium)

33. Premiums:
 Single national premium based on estimated
costs, including admin.
 No adjustments for age, family status or
tobacco use
 Allows employers to pay on employee’s
behalf
 Medigap policies - “guaranteed issue” basis

34. Premium Subsidies/Tax Credits/Cost
Sharing:
 Generally, follow ACA rules (138% -
400% FPL)
Providers/Facilities:
 Must participate if already accepting
traditional Medicare
 Paid at Medicare rates

35. Costs:
Subsidies, Credits & Cost
Sharing
$500M per yr. (1st 3 yrs.) for
enrollment assistance
No CBO cost estimates yet

36. Eligibility:
 US residents and groups eligible for the
ACA marketplace
Benefits:
 ACA - 10 essential health benefits
 Number of Levels (i.e.: Gold, Silver,
Bronze) offered vary

37. Enrollment Process:
 ACA marketplace enrollment procedures
& rules
Premiums:
 To cover 100% of benefits & admin. costs
+ contingency
 Can vary based on age, geography,
family size, & tobacco use

38. Premium Subsidies/Tax Credits/Cost
Sharing:
 Generally, ACA rules
 Expands eligibility to 600% FPL (up
from 400%)
 Ties cost-sharing to Silver Plan

39. Providers/Facilities:
Must participate if already
accepting traditional Medicare
Limited opt-out provisions
Generally, paid at Medicare
rates

40. Costs:
Subsidies, Credits & Cost
Sharing
Office of the Ombudsman
No CBO cost estimates yet

42. M4A:HowtoPayforIt
 Elimination of certain tax breaks
• Exclusion of employer-paid premiums
from payroll/income taxes
• Personal medical expense deduction
• $4.2T over 10 years

43. M4A:HowtoPayforIt
 7.5% income-based premium on employers
• 1st $2M of salaries exempt (ode to small
business)
• $3.9T over 10 years
 4.0% income-based premium on households
• $3.5T over 10 yrs.

44. M4A:HowtoPayforIt
• Make personal income tax more
progressive
• Marginal rates begin to increase at
$250K
• Top out at 52% (vs. 37%)
• $1.8T over 10 yrs.

45. M4A:HowtoPayforIt
• Establish a wealth tax on top 0.1%
• Would affect 160,000 households
• 1% tax on net worth > $21M
• $1.3T over 10 years

46. M4A:HowtoPayforIt
• Other
• Make estate tax more progressive
• One-time tax on off-shore profits
• Fee on large financial institutions
• Close loopholes/acct. gimmicks
• $1.5T over 10 years
Total = $16.2T over 10 years (need $32.6T??)

48. • Co-Sponsor of Bernie’s M4A Bill
• Co-Sponsor of less ambitious “State Public
Option Act”
• June 26th debate: “I’m with Bernie on
Medicare for All”
• No indication she will release a healthcare
proposal of her own
• Staying away from the “T” word

49. • Sept. 12th Debate:
• “Those at the very top, the
richest individuals and the
biggest corporations, are going
to pay more, and middle-class
families are going to pay less”.

50. • Sept. 12th Debate (cont.):
• “What families have to deal with is
cost, total cost. What we’re talking
about here is what’s going to
happen in families’ pockets, what’s
going to happen in their budgets.
For hard-working families across this
country, costs are going to go down”.

52. •Not a supporter of “Medicare for All”
•Wants to build on the ACA by adding a
public option
•Hasn’t formally endorsed any
proposed legislation
•Everyone eligible (whether covered
thru your employer or buying on your
own)

53. •Use Gold plan as benchmark (lower
deductibles & co-payments)
•Make subsidies more generous
•Eliminate 400% FPL cap for tax credit
eligibility
•Lower “cost-of-healthcare” cap to
8.5% of income

54. •No Premium for those between 100 –
138% FPL in non-expansion states
•Reduce costs for patients by negotiating
lower prices from hospitals and other
health care providers
•Pay for via higher capital gains taxes on
the “rich”
•One estimate: $750B over 10 yrs.

56. •Not a supporter of “Medicare for All”
•Not a supporter of a public option
•Not a supporter of The Affordable Care Act
•Not a supporter of free healthcare for illegal
immigrants
• Supported by all Democrat candidates
• Could cost up to $23B/year

57. • 5th Circuit Court of Appeals case pending
• Decision could come soon
• ACA could be declared unconstitutional
• Risk to White House if alternative plan
not in place – imminent?
• Going to Supreme Court either way

58. •Focused on:
• Strengthening Medicare (recent
Executive Order)
• Legal immigrants must prove coverage
• Medicaid work requirements
• Price transparency
• Verbal support for current drug pricing
legislation in House & Senate

59. -Guinness or Sam
Adams Octoberfest?
-Or Both?