Stepchild of Health Care Now Getting Overdue Attention

People are living longer and the population of older adults is growing, but long-term care remains a stepchild in debates over health care. That is beginning to change as presidential candidates offer options for expanding long-term benefits for older adults and people with disabilities. With only a small percentage of older adults who have private long-term care insurance, the challenge and costs of expanded benefits are daunting.

People are living longer and the population of older adults is growing, but long-term care remains a stepchild in debates over health care. That is beginning to change as presidential candidates offer options for expanding long-term benefits for older adults and people with disabilities. With only a small percentage of older adults who have private long-term care insurance, the challenge and costs of expanded benefits are daunting.

Long-term care has been the missing link in health care reform debates, but that is changing as 2020 Democratic presidential candidates offer options for addressing the arguably biggest gap in the US health care system.

The Medicare-for-All plan introduced by Vermont Senator Bernie Sanders and supported by several Democratic presidential candidates adds long-term care benefits to Medicare. Independent estimates place the cost for expanded benefits at $25 trillion over 10 years.

A House version of Medicare-for-All, cosponsored by Washington Congresswoman Pramila Jayapal and Michigan Congresswoman Debbie Dingell, which emphasizes policies that allow older adults to remain in their homes. "Instead of saying institutional care is the default, we say you should be able to get care at home, in your community," Jayapal says.

New Jersey Senator Cory Booker recently unveiled a proposal to expand eligibility for long-term care services for older adults and disabled persons under Medicaid. Roughly 20 percent of Medicaid spending goes toward long-term care. About 65 percent of nursing home residents are supported primarily by Medicaid.

Minnesota Senator Amy Klobuchar has a “Plan for Seniors” that seeks to expand long-term care facilities, add hearing, vision and dental care to Medicare and support training for long-term caregivers. Klobuchar wants to bolster Social Security by lifting the payroll tax from the current $133,000 income cutoff to wages up to $250,000. 

Political dialogue about long-term care has been sparked by data showing projected growth in the number of older adults in the US population. By 2035, there are expected to be 78 million people 65 years and older compared to 76.7 million people under the age of 18. As few as 8 million Americans have some form of private long-term care insurance. There also has been a strong push by disabled Americans to strengthen long-term care.

Older Americans make up one of the most consistent voting blocs and they tend to be more conservative than younger voters. Democrats sniff an opportunity to eat into a bedrock conservative cohort by advancing long-term care initiatives.

AGE+,  a new nonprofit, has formed to address long-term care issues holistically in Oregon with an emphasis on aging in place and addressing equity for underserved older adults in rural areas and minority communities.

AGE+, a new nonprofit, has formed to address long-term care issues holistically in Oregon with an emphasis on aging in place and addressing equity for underserved older adults in rural areas and minority communities.

Providing long-term care benefits under Medicare or Medicaid will be expensive. The dimensions of the problem go beyond money. There aren’t enough long-term care beds available, there are too few single-story homes where disabled and older adults could age in place and there is already a shortage of trained caregivers. Add to that isolation that can occur, especially in rural areas, and inequities in available long-term care options. Low pay is a barrier to recruiting more caregivers.

Gerontology researched Marc Cohen describes long-term care as the stepchild in the broader health care reform discussion. Nicole Jorwic, policy director for The Arc that serves people with disabilities, says, “If you don't include long-term supports and services, it cannot be considered a bill that is for all people because it leaves out huge portions of the population, including people with disabilities and aging Americans."


The Curiously Missing Debate on the US Economy

President Trump focuses on immigration and tariffs and only occasionally cites strong US economic performance. Democratic presidential candidates are trying to win over primary voters by discussing issues such as universal health care, college debt and social justice. The result is a missing debate on the state and future of the US economy, which polls show is the top priority of a majority of voters.

President Trump focuses on immigration and tariffs and only occasionally cites strong US economic performance. Democratic presidential candidates are trying to win over primary voters by discussing issues such as universal health care, college debt and social justice. The result is a missing debate on the state and future of the US economy, which polls show is the top priority of a majority of voters.

A surging stock market, continued job creation and historically low unemployment have led to rising levels of public approval of Donald Trump in the polls. 

On the flip side, soaring federal budget deficits, protracted trade wars affecting industrial and agricultural sectors and tariffs threatening higher consumer prices are posting warning signs of an impending downward economic cycle, perhaps just before the 2020 election. 

Despite the stakes, bread-and-butter economic policy has taken a decidedly back seat in political debates, even as polling shows the economy remains the top priority of voters. 

Skillfully or impulsively, President Trump focuses on immigration, ‘creeping socialism’ and denigrating Democrats, while only occasionally praising the economy he’s overseen for 2½ years. Democratic presidential candidates, many seeking to curry favor with the increasingly restive progressive wing of the party, talk about health care, immigration reform, college debt, wealth taxes, climate change, social justice and Trump. 

Democrats also campaign in the shadow of the Mueller report and growing calls to impeach Trump. At times it seems as if Trump and his media allies egg on articles of impeachment, which face an uncertain fate in the Democratic House, but certain death in the Republican Senate. 

Absent in most Democratic stumping is any serious, sustained criticism of Trump economic policy. If criticism was to occur, this is what it might look like: 

Budget Deficit: According to the Treasury Department, the federal budget deficit ballooned 77 percent in the first four months of 2019 to $310 billion, up from $176 billion during the same period a year earlier. That period included the largest single month deficit. One reason for the larger deficits was a sharp drop in tax revenue, attributed to the Trump tax cuts. Meanwhile, federal spending has increased 9 percent, including a 12 percent hike in military spending and a 16 percent rise in Medicare outlays.

The Congressional Budget Office has projected a $900 billion deficit this fiscal year. The Office of Management and Budget, which is overseen by the Trump administration, projects the deficit will reach nearly $1.1 trillion – and keep rising through the 2020 fiscal year.

The Trump administration has not pushed very hard for federal spending reductions, settling instead for sending Congress a budget with cuts to Medicare, Medicaid and Social Security, which are political non-starters.

Trump has seemingly walked away from his promise of a major infrastructure investment plan. His own advisers have warned he cannot boost military spending and build new roads and bridges at the same time, especially when congressional Republicans appear unwilling to vote for the taxes to pay for upgraded infrastructure.

The political punch: The economy is cruising along, but only because it is fueled by the equivalent of credit card debt on steroids. The tax cuts and spending spree have effectively ruled out long-term investments in roads and bridges. 

Trade Wars: True to his campaign promise, Trump has upset the trade apple cart by imposing tariffs, first on steel and aluminum, then more generally, with a special gusto for Chinese imports. Trump also has selectively imposed sanctions on Iran and Venezuela. His trade team succeeded last year in negotiating an updated version of the North American Free Trade Agreement, but it still hasn’t been approved by Congress.

The Congressional Budget Office shares its data about federal deficits, budget and revenue projections and marginal tax rates, as well as statistical information about many specific federal programs. If you want to be the smartest person in the room when it comes to the economy, check this out: .

The Congressional Budget Office shares its data about federal deficits, budget and revenue projections and marginal tax rates, as well as statistical information about many specific federal programs. If you want to be the smartest person in the room when it comes to the economy, check this out:

Trump claims his tariffs have revived the US steel and aluminum industries and produced substantial revenue. The nonpartisan Tax Foundation confirms tariff revenue reached $70 billion by the end of May 2019, while reducing the US Gross Domestic Product by $50 billion, lowering wages by .13 percent and resulting in a loss of nearly 156,000 American jobs. 

The Tax Foundation also computed the impact of tariffs Trump threatened to impose against China, automobiles and Mexican products. Estimated revenues would exceed $154 billion at a cost of $112 billion in lost GDP, .3 percent decline in wages and loss of nearly 350,000 US jobs.

Then there are retaliatory tariffs by the European Union, India, Turkey, Mexico, Canada and Russia. The US treasury receives no revenue from these tariffs, but lost GDP from them tops $21 billion, wages decline .05 percent and some 67,000 jobs disappear. 

“If all tariffs announced thus far were fully imposed, US GDP would fall by 0.74 percent ($184.07 billion) in the long run, effectively offsetting about 44 percent of the long-run impact of the Tax Cuts and Jobs Act. Wages would fall by 0.48 percent and employment would fall 570,591,” according to the Tax Foundation. 

The tariffs have worked a particular hardship on American farmers who have seen foreign markets evaporate, income nosedive and price increases for new equipment. The Trump administration conceded the impact on farmers, won approval for a $12 billion bailout and is seeking another $16 billion to aid farmers. Adding injury to insult, the major beneficiaries of the first bailout flowed to larger corporate farms, not family farms and “patriot farmers.”

The political punch: Tariffs are taxing Americans, raising prices, lowering wages, hurting farmers, losing jobs and posing a threat to continued economic growth. And, they haven’t resulted, at least so far, in great trade deals either.

Looming Downturn: Signs are emerging that an economic downturn may be on the horizon. Economists warn an escalating trade war combined with slowing growth in China and internationally could tip the economy into recession.

There also are troubling indicators.

  • Historically and ironically, recessions occur just when retail sales, industrial production and employment peak, as they have. Household wealth and income also peak just before a downturn.

  • Another historical indicator of recession is when interest rates on long-term bonds are lower than interest rates for short-term bonds for three continuous months, as just happened. This isn’t just a US phenomenon; it is occurring in bond markets around the world. 

Sensing the possibility of a declining US economy heading into an election, Trump has been hectoring Jerome Powell, the man he chose to head the Federal Reserve Board, to cut interest rates. After resisting such action, Powell in congressional testimony last week hinted an interest rate cut may be in the offing as early as this month. 

Powell told Congress, “Based on incoming data and other developments, it appears that uncertainties around trade tensions and concerns about the strength of the global economy continue to weigh on the US economic outlook.”

The stock market was ecstatic and hit new record highs. Critics warned an interest rate cut now will limit the Fed’s ability to combat a recession when it inevitably occurs.

The political punch: With increased deficit spending, continuing tariffs and a demand for lower interest rates, the administration is playing with fire, dousing a fire and trying to light a fire all at once.

You heard it here, even if you won’t hear anywhere else.


Best Bipartisan Opportunity: Lowering Prescription Drug Prices

The best opportunity in a fractious Congress for bipartisan legislative success appears to be in an effort to curb prescription drug prices, which critics say are higher than charged in other Western countries and are forcing some Americans to ration prescriptions or even avoid treatment.

The best opportunity in a fractious Congress for bipartisan legislative success appears to be in an effort to curb prescription drug prices, which critics say are higher than charged in other Western countries and are forcing some Americans to ration prescriptions or even avoid treatment.

If a bipartisan deal is going to be struck this year, it will deal with lowering prescription drug prices, according to an Axios report.

“The White House and top lawmakers from both parties think a bill to lower drug prices has a better chance of becoming law before the 2020 election than any other controversial legislation,” says Caitlin Owens of Axios. “Republican politics on drug prices have changed rapidly. The White House has told Democrats it has no red lines on the substance of drug pricing – a position that should leave pharma quaking.”

The only red line for the White House is tying drug legislation to revisions of the Affordable Care Act. But Trump officials have given the green flag to using Medicare negotiations as leverage to lower drug prices.

Axios indicates momentum is growing for legislative action before the August recess, viewed by many as the last fertile moment for compromise before the start of the 2020 presidential election political desert when nothing can get approved. Bills are already moving in Congress aimed at influencing drug prices by limiting extended monopolies and expanding access to generic prescription drugs.

Republicans are introducing bills that previously would have been viewed as liberal. Texas Senator Mike Cornyn proposes giving the Federal Trade Commission the power to bring antitrust suits against pharmaceutical companies that use patents to discourage competition. House GOP leader Mark Meadows is part of a bipartisan group exploring a proposal to tie Medicare reimbursement rates to the international price of prescription drugs. Florida Senator Rick Scott introduced legislation preventing US drug companies from charging higher list prices than in Canada, France, Britain, Japan and Germany.

This spate of activity around drug pricing has put the pharmaceutical industry on high alert. Drug company officials have warned proposed legislation could slow investments in promising new drug treatments and upset the “pharmaceutical ecosystem.” That is an appeal aimed at President Trump who has expressed strong support for drug therapy advancement. 

Getting anything of significance accomplished in Congress is never easy. Partisan fights over what to do in response the Mueller report, health care and border security could derail any bipartisan effort on prescription drugs. The embrace by Democrats for a single-payor Medicare for All system could be a particular problem in that it could exacerbate the existing price differences between Medicare and private health insurance.

“Anything that gets done would need to be passed before the August recess, which itself is growing more unlikely as time passes and fights over the ACA and other issues erode whatever bipartisan collaboration that might have existed," a former Trump administration official told Axios.

The prospect of legislative action on drug pricing, supported by the Trump administration, has taken its toll on the stock prices of major pharmaceutical companies – and sharply lowered the multi-million compensation of their CEOs.

Dems Manage Only Blue Ripple in Midterm Election

The projected blue wave was reduced to a blue ripple as Democrats regained control of the House, but Republicans retained their hold on the Senate, setting the stage for split government and potentially more partisan bickering.

The projected blue wave was reduced to a blue ripple as Democrats regained control of the House, but Republicans retained their hold on the Senate, setting the stage for split government and potentially more partisan bickering.

What was perhaps the most anticipated midterm election in recent memory went largely as polls and pundits predicted it would – a sharp contrast from two years ago. Democrats leveraged their fury over President Trump to recapture the House, while Republicans expanded their majority in the Senate, a split verdict presaging divided government and partisan conflicts for the rest of Trump’s first term.

The campaign efforts of Trump and GOP members mobilized enough Republican voters to reduce a projected Democratic blue wave to something closer to a blue ripple. Presidential campaigning helped Republicans win hotly contested Senate races in Indiana, Missouri, North Dakota, Tennessee and Texas. Trump proclaimed the election outcome a “tremendous success” as Republicans held their grip throughout the South and in rural and exurban areas.

But Democrats – propelled by a rejection of Trumpism in the nation’s suburbs, and especially from women and minority voters – notched victories in areas that just two years ago helped Trump reach the White House. Incumbent Republicans fell in an array of suburban House districts, including one held by House Rules Committee Chairman Pete Sessions in the Dallas area. And in West Virginia – where Trump is wildly popular and campaigned heavily for Republicans – the reelection of Democratic Senator Joe Manchin delivered a personal blow to the president.

In Washington’s 3rd District, 4-term GOP Congresswoman Jaime Herrera Beutler squeaked out a victory over Democratic challenger Carolyn Long, who mounted a serious, well-funded challenge and sounded like she will try again in 2020.

Democrat Kim Schrier, a pediatrician making her first political run, defeated two-time GOP gubernatorial candidate Dino Rossi in Washington’s open 8th District. Republican Congressman Dave Reichert chose not to seek re-election. The Schrier-Rossi contest was one of the most expensive House races in the nation. Her victory bumps up the double-digit Democratic margin in the House and further increases the number of women who will serve in the 116th Congress. The 8th District has never sent a Democrat to Congress before Schrier.

In the high-turnout election, Democrats picked up at least seven governorships, performing well across much of the upper Midwest and even in ruby-red Kansas, where Laura Kelly was elected governor over the President’s handpicked candidate, Kris Kobach.

In Wisconsin, Democrat Tony Evers bested Governor Scott Walker, once a Republican star who ran for president in 2016. Walker survived a hard-fought recall vote in 2012 and was reelected in 2014. Democrats failed to take over the Florida governorship left open by Rick Scott, who challenged incumbent Democrat Senator Bill Nelson and held a slight edge in a tight race that may be headed for a recount. Trump-backed Ron DeSantis narrowly defeated progressive Democrat Andrew Gillum in a race that might be a preview of the 2020 presidential election if Trump faces one of the more left-leaning challengers eying the race. 

House of Representatives 

As expected, Democrats regained control of the House for the first time since Republicans took the majority in 2010. Returns early Wednesday show Democrats poised to pick up more than the 23 House seats they needed to gain a foothold in Congress from which to counter Trump.

Democrats were projected to flip at least 29 districts currently held by the GOP, while they were on track to surrender only a few seats in the chamber. As of now, Democrats have taken 220 seats (enough for the majority) and Republicans have 194 seats. That leaves 21 seats still on the board, including the two close races in Washington. 

With Democrats in charge, Trump will face a different set of committee chairmen who seem poised to investigate alleged administrative corruption and will have subpoena power to push their investigations. Democratic Congressman Adam Schiff will ascend to the chairmanship of the House Intelligence Committee, which will translate into more discerning oversight into the potential of Trump team collaboration with Russian operatives in the 2016 presidential election, a sharp turn from the sycophantic role of GOP Congressman Devin Nunes. The Mueller investigation also will have a solid firewall.

Maybe the biggest irony of the 2018 midterm election was that defending Obamacare may have propelled Democrats back into control of the House after costing them their majority in 2010 following its passage.


In the Senate, the GOP was able to take advantage of a favorable map heavily tilted toward Republican-friendly states where Trump remains popular. The GOP scored a series of wins in those states, with only a few setbacks. Incumbent GOP Senator Dean Heller of Nevada was unseated by Jacky Rosen. And in West Virginia, a state Trump carried by 42 points in 2016, incumbent Democrat Senator Joe Manchin retained his seat. 

But with GOP pickups in Indiana, Missouri, and North Dakota, and likely Florida, the GOP expanded its grip on the Senate for Majority Leader Mitch McConnell, increasing the GOP’s narrow 51-49 seat majority. We can expect McConnell’s Senate to retain a focus on confirming Trump’s appointments to the judiciary over the next two years and ignore legislation sent over from the Democratic House that would undermine the Trump agenda.

It’s important to note that in 2020, the Senate map is nearly the exact opposite of this year with 21 Republican-held seats up for election compared to just nine Democratic seats.

Oregon and Washington Elections

There were no shockers in Oregon. The state’s five incumbent members of Congress were swept back into office. Suzanne Bonamici, Earl Blumenauer, Peter DeFazio, Kurt Schrader and Greg Walden, who have served a collective 69 years in the House, will return for another two years, but in a House chamber markedly different than in the previous eight years.

Perhaps the most interesting result was in Oregon’s 2nd District where Republican Greg Walden won his 11th term by defeating Jamie McLeod-Skinner 57.5 percent to 38.06 percent. Though he still won comfortably, the tally was a sharp decrease from the 69.9 percent Walden posted in 2016.

Senator Maria Cantwell cruised to victory as did GOP Congresswoman Cathy McMorris Rodgers and the remainder of Washington’s Democratic congressmen.

Congresswoman Jaime Herrera-Beutler is expected to eke out a victory in the 3rd District, while Democrat Kim Schrier leads Dino Rossi by 53 to 47 percent margin.

Legislative Prospects in the Next Congress 

With little chance of getting major legislation through the Senate, congressional Democrats will remain on the sidelines for federal judicial confirmations in the Senate, play the role as pesky thorn in the side of Trump in the House and, in turn, serve as a predictable foil in Trump’s anticipated 2020 re-election bid. 

Democrats may get an early start on their fall-guy role with a vote to restore Congresswoman Nancy Pelosi as Speaker of the House, who has become a familiar political piñata at Trump campaign rallies.

Oregon Congressman Peter DeFazio is on track to become chair of the House Transportation and Infrastructure Committee, which raises hope of a more serious effort to push a major infrastructure package in the next Congress – one of the few possible bipartisan legislative projects in a split Congress. 

Strong voter interest in health care expressed in the midterm elections might prompt bipartisan efforts to shore up popular provisions of the Affordable Care Act. 

It seems less likely bipartisan common ground can be found in the next two years on Medicare and Medicaid and on immigration reform, which may be headed for the 2020 presidential election as political wedge issues.

Walden will lose his chairmanship of the influential House Energy and Commerce Committee, but will continue as the Ranking Member. Walden has a track record of advancing legislation in divided government and may look for bipartisan wins to shore up support back home. 

With the GOP retaining control of the Senate, Washington Senators Patty Murray and Maria Cantwell and Oregon Senators Ron Wyden and Jeff Merkley aren’t expected to take on any new committee assignments. But they will enjoy increased bargaining positions over appropriations and other legislation where they have a Democratic partner to dance with on the House side. 

The “lame duck” Congress now becomes very important to Republicans who will try to accomplish some political objectives before the 116th Congress convenes in January. An aggressive GOP push on contentious issues in the lame duck session could poison the well for any possible collaboration in the next Congress, but it could bolster Republican efforts to satisfy their political base.


Senate Reaches Bipartisan Deal with Sharp Spending Increases

The US Senate reached a 2-year budget deal that sharply increases defense spending and for a range of health care programs. The deal, which will boost the federal deficit and doesn’t deal protection of Dreamers, still must pass muster in the House and with President Trump, even though it doesn’t appear to provide funding for his border wall

The US Senate reached a 2-year budget deal that sharply increases defense spending and for a range of health care programs. The deal, which will boost the federal deficit and doesn’t deal protection of Dreamers, still must pass muster in the House and with President Trump, even though it doesn’t appear to provide funding for his border wall

[UPDATE: Early on Friday, February 9, the Senate passed a continuing resolution in effect until March 23 that authorizes spending levels contained in the bipartisan Senate budget deal. Later in the morning, the House passed the continuing resolution and President Trump signed it. The temporary government shutdown lasted only a few hours. Federal government employees reported to work as normal.]


The Senate reached a bipartisan budget deal that will boost federal spending by $300 million over the next two years and suspend the debt ceiling for one year, but without resolving immigration issues. The House and President Trump still must agree, which is not automatic.

House conservatives voiced concern about increased spending that will push up the federal deficit even further after GOP-backed tax-cut legislation late last year. House Democrats were furious the Senate deal didn’t include protection for Dreamers who may face deportation after Trump’s March 5 deadline. Speaker Paul Ryan said he believes the votes exist in the House to approve the Senate compromise.

There also may be some procedural issues slowing the vote in the Senate that could result in a temporary government shutdown scheduled for midnight tonight. And President Trump has yet to officially sign off on the deal, which doesn’t appear to include money for his border wall.

The biggest spending increase goes for defense – $80 billion in Fiscal Year 2018 and $85 billion in Fiscal Year 2019. Caps on non-defense discretionary spending would increase by $63 billion this year and $68 billion next year. Almost $90 billion is provided for disaster relief. There appears to be a $20 billion down payment on the Trump infrastructure package.

The increases give both political parties plenty to crow about and resolve a nagging budget issue that is a hangover of sequestration that went into effect in 2011.

If the Senate budget deal survives, congressional appropriators are expected to write an omnibus FY 2018 appropriations bill that moves up total spending from $1.065 billion allowed under current law to $1.208 trillion as provided in the Senate budget agreement.

The deal also includes some other significant provisions:

  • A one-year extension of expired tax breaks that were not included in the December 2017 tax reform bill, including the Alternative Fuels Tax Credit.
  • Four additional years of extension of the CHIP program after the six-year extension enacted last month runs out.
  • Two years of renewed funding at around $7 billion for community health centers, $6 billion for mental health treatment and opioid addiction and $2 billion in additional funding for the National Institutes of Health. Notably absent, however, was funding to shore up the Affordable Care Act, which was the concession promised to Maine Senator Susan Collins in return for her vote for the GOP tax cut. The deal does continue to delay any cuts to hospitals that serve a disproportionately high share of low-income patients.
  • Accelerated elimination of the “doughnut” in Medicare in pre-catastrophic care drug coverage and elimination of the controversial Medicare Payment Advisory Board. The limit on Medicare coverage for physical therapy would be permanently repealed.
  • $500 million to the National Health Service Corps and $363 million for the Teaching Health Center Graduate Medical Education program to encourage doctors to practice in underserved areas.
  • Creation of a new Joint Select Committee on Solvency of Multiemployer Pension Plans, to produce legislation fixing the Pension Benefit Guaranty Corporation by December 2018 with a guarantee that the bill will get a vote in the Senate under “fast track” procedures.
  • Creation of a new Joint Select Committee on Budget and Appropriations Process Reform, to produce legislation fixing the broken congressional budget process by December 2018 with a guarantee that the bill will get a vote in the Senate under “fast track” procedures.

An estimated $100 billion in “pay-fors” were included in the package to mitigate the effect of non-defense spending on the federal deficit. They include:

  • An extension of the portion of Transportation Security Administration aviation security fees that go towards deficit reduction into fiscal 2026 and 2027, estimated to total $1.64 billion in 2026 and $1.68 billion in 2027.
  • Selling oil from the Strategic Petroleum Reserve.
  • Taking money from the Federal Reserve’s surplus fund.
  • Extending sequestration of non-exempt mandatory programs (mostly Medicare) into fiscal 2026 and 2027.

    Joel Rubin is a partner and leader of CFM’s federal affairs team based in Washington, DC. He has worked on Capitol Hill and now represents Pacific Northwest interests in Congress and with federal agencies.

The Search for an Obamacare Alternative

Congressional Republicans have failed so far to offer a comprehensive alternative to Obamacare, but there is a surge of support on the campaign trail to look at a single-payer health care system.

Congressional Republicans have failed so far to offer a comprehensive alternative to Obamacare, but there is a surge of support on the campaign trail to look at a single-payer health care system.

While congressional Republicans continue to look for an Obamacare replacement, others are stepping up with alternatives they may like even less but may appeal to a significant segment of the U.S. population.

Democratic presidential candidate Bernie Sanders has been a consistent voice for a single-payer national health care system, which could be a simple as having everyone enrolled in Medicare. His support for a single-payer health care system is credited by some political observers for his strong showing in early Democratic presidential polls as he challenges Hillary Clinton, who also has a reputation for health care reform.

The single-payer system Sanders has supported on the presidential stump is estimated to cost $15 trillion over 10 years. But Sanders and like-minded supporters say a single-payer system would eliminate $5 trillion in “administrative waste" in that same period. The plan would be paid for by what is described as a “progressive” payroll tax

A Colorado group has placed Initiative 20 on that state's 2016 general election ballot to create ColoradoCare. Under this universal health care coverage proposal, people who live or earn money in Colorado could choose their providers, but medical bills would be paid by the state.

Backers of the Colorado initiative would pay for ColoradoCare through a 10 percent payroll tax, which would generate an estimated $25 billion per year. Under the plan, employers would pay two-thirds of the 10 percent payroll tax and employees the remaining one-third. Self-employed individuals would pay the entire 10 percent on their net income, according to The Denver Post.

The concept of a national single-payer health care system has been floated before and generally beaten back because of fears of an even larger federal bureaucracy, increased health care costs and higher taxes. Hillary Clinton’s proposed health care reform measure stopped short of a single-payer system, as does the Affordable Care Act, which tries to reduce the number of people without health insurance by creating a government-managed marketplace.

While it is easy to point at warts in Obamacare, it is much harder to come up with a plan to replace it, which is why congressional Republicans have voted scores of times on repeal and zero times on a substitute. One reason for the difficulty is that the U.S. health care system has lots of parts. There is the part where workers and their families receive health insurance offered through their employer. Then there is Medicare, Medicaid, the Veterans Administration, Indian Health, federally funded clinics, school clinics, psychiatric care and alternative care such as naturopathy and chiropractic.

The complex health care system and health insurance coverage only partially overlap, which sometimes leads to awkward and expensive health care delivery, such as children from low-income families being forced to seek care in a hospital emergency room instead of a school clinic or people suffering from mental illness receiving prescriptions for psychotropic drugs from primary care physicians.

One of the underlying appeals of a single-payer system is its promise to consolidate the silos in the health care delivery system and eliminate (or at least shrink) the disparity between health care delivery and health insurance.

Skeptics question whether a single-payer health care system would live up to its promise in the United States, where many people are accustomed to a broad range of choices in providers and some providers decline to serve patients in a public health program because of lower fees. Skeptics also doubt Americans are willing to pay higher taxes and hand over more control of their lives to the federal government.

While those arguments have prevailed in the past, progressives such as Sanders and the Initiative 20 backers in Colorado are saying that tinkering with the health care system is not enough to stem rising health care costs and ballooning insurance premiums. They say if you want an alternative to Obamacare, here’s one to consider.

In the absence of another comprehensive alternative, the single-payer system appears to be gaining some momentum as a policy option.

The End of an Era of Committee Dominance

Age and the wear-and-tear of polarized politics are taking their toll in Congress. The longest serving member of Congress in history announced this week he will retire.

Congressman John Dingell, Jr., the son of a congressman who also represented what has become a staunchly Democratic district in the suburbs of Detroit, has seen a lot of history and made a lot of history in nearly 60 years on Capitol Hill. Operating as chairman of the House Energy and Commerce Committee, Dingell left his fingerprints on legislative achievements from creating Medicare, environmental laws and civil rights legislation.

Perhaps nowhere was his powerful grip felt most than when it came to protecting Detroit's Big Three automakers from ambitious Presidents and restless congressional colleagues. It is notable that Congressman Henry Waxman, the California Democrat who unseated Dingell as chair of the Energy and Commerce Committee over his foot-dragging on stricter vehicle emission standards and climate change measures, also announced his retirement from Congress earlier this year.

Dingell referred to himself as a Social Democrat, a tradition he inherited and embraced from his father who introduced national health insurance legislation in 1943. Dingell supported the Affordable Care Act, though he said it didn't go far enough. He championed a more aggressive single-payer national health system.

The imposing 6-foot, three-inch Dingell assumed command of the Energy and Commerce Committee in 1981, the year Oregon's Ron Wyden landed in Congress and earned a seat on the powerful panel. Dingell spread his wings to collect broad jurisdictions over health care, the environment, telecommunications and consumer protection. He leveraged that widening jurisdiction like a hammer in oversight hearings, where Dingell grilled Republican and Democratic witnesses with the same fervor.

Oregon Gets Good Marks on Medicare Spending

Helping senior citizens remain in their homes is given credit for holding down per enrollee Medicare spending in Oregon.

Oregon's $8,247 per Medicare enrollee average is among the lowest in the nation and far below the $10,365 average expenditure nationwide. Washington's average is slightly higher at $8,497 and Idaho's is lower at $7,880, according to data compiled by the Kaiser Family Foundation.

The Portland Business Journal reported on the findings in its online edition this week, citing a study by the Institute of Medicine that concluded post-hospital services account for most of the variation in Medicare spending. The study pointed to uneven spending on nursing homes, long-term care hospitals, home health care and inpatient rehabilitation as responsible for 73 percent of the variability in average Medicare spending state-by-state.

Northwest Given Key Role on New Budget Panel

One of the key provisions included in the debt limit and funding agreement signed last night was formation of a House-Senate Budget Conference Committee. The Pacific NW is well represented on the newly formed, 29-member committee with Senators Patty Murray (D-WA), Ron Wyden(D-OR), Jeff Merkley(D-OR) and Mike Crapo (R-ID).

The newly constituted committee is tasked with hammering out differences between the House and Senate FY14 spending levels. The House spending level is $90 billion lower than the Senate proposal.  The Committee is required to report on an agreement by December 13.  However, unlike the Supercommittee established in 2011, there is no penalty for failure. 

There is faint optimism that both sides can come together on a "baby" grand bargain to lift temporarily the sequestration spending caps by making cuts to entitlement programs such as Social Security and Medicare.

As you could guess, optimism is subdued by a meager track record of agreement and the hyper-partisan climate in Washington.  However, both sides seem interested in raising the sequestration caps.  Democrats want to increase domestic spending levels and Republicans defense spending.  Both sides feel programs are being severely squeezed under the caps and thus there may be room for a small, short-term deal. 

Wyden Talk in a Tweet

Oregon Senator Ron Wyden covered a wide range of topics at his speech today, but none drew closer attention than his remarks about how to secure privacy from government surveillance. With Congress in recess before a tumultuous fall session dealing with the budget, senators and representatives are hitting the hustings to reconnect with their constituents. Oregon Senator Ron Wyden spoke at a luncheon meeting of the Westside Economic Alliance.

His comments and answers to questions covered the federal budget, Medicare, taxation, international trade, energy exports, national security and Obamacare, as well as more local issues. Here is the essence of what he said in a series of tweets:

  • Sen. Wyden promises new bipartisan Medicare plan to preserve its guarantee and financial integrity as 10K people turn 65 daily for 20 yrs.

  • Sen. Wyden says simplified federal tax code can unleash ton of corporate cash sitting on the sidelines for job-creating investment.

  • Wyden predicts congressional revision of Patriot Act's "relevance" standard and a privacy advocate before FISA court.

  • Wyden says choice between safety and privacy is false in the face of continuing terrorist threats. Both are critical and can co-exist.

Report Discourages Medicare Value Index

Oregon shows up well in a National Academy of Sciences study on keys to Medicare spending and reimbursement.In the corners of the ongoing Medicare debate is the issue of variability of Medicare payments in different regions of the country. It long has been a complaint in the Pacific Northwest that Medicare reimbursement is lower than elsewhere in the nation because of the region's commitment to managed care and holding down medical costs.

Now the National Academy of Sciences' Institute of Medicine has released the findings of its three-year study on the subject, along with a recommendation discouraging Congress from implementing a "value index" to give favored funding to regions offering high-quality medical care at the lowest prices.

Pressure for the study came from political leaders in states such as Minnesota and Iowa, which boast of lower spending on health care spending. However, the Institute of Medicine report debunked most claims, saying medical spending variability often is as great within regions as it is among states.

Wyden Could Be a Tax Panel Kingpin

Oregon Senator Ron Wyden could find himself chairing the powerful Senate Finance Committee in the next Congress following if Democrats can hold on to control of the Senate in the 2014 elections.Oregon Senator Ron Wyden may be next in line to become chairman of the Senate Finance Committee, which overseas taxation, trade and Medicare. The one hitch is that Democrats will have to fight to retain control of the Senate in the 2014 elections.

Wyden's potential ascension is due to the announcement today that current Chair Max Baucus, a Montana Democrat, has decided not to seek reelection. Earlier, the ranking Democrat on the committee, West Virginia Democrat Jay Rockefeller, said he was retiring.

The bad news for Wyden is that it may be hard for Democrats to retain those two Senate seats and a few others in the 2014 mid-term elections when there isn't a presidential race to activate all Democratic constituencies.

Elected to the U.S. House in 1980, Wyden moved into his first major chairmanship this term by taking the gavel of the Senate Energy and Natural Resources Committee. It takes that long in seniority-based Congress to move to the front of the line.

For a small state like Oregon, having the chairmanship of one of the most powerful committees in Congress is a big deal. Former Senator Bob Packwood chaired Senate Finance in the early 1980s and engineered a major tax overhaul. At the same time, the late Senator Mark Hatfield chaired Senate Appropriations, which made the two Oregon senators among the hottest phone numbers in DC.

Rhetoric Aside, Both Sides Favor Medicare Limit

Despite fierce campaign rhetoric, one business commentator says President Obama and GOP challenger Mitt Romney largely agree Medicare needs to go on a spending diet.Medicare has emerged as a defining issue in this year's presidential campaign, but one iconoclastic commentator says President Obama and his GOP challenger Mitt Romney actually agree more than they disagree on what to do.

Matthew Yglesias, who covers business and economics for Slate, says despite fiery campaign rhetoric, both sides have committed to putting Medicare "on a diet." How they would shrink Medicare spending differs, Yglesias says, but that difference pales in comparison to their agreement on imposing a finite spending limit on one of America's most popular entitlement programs, which expands as medical costs rise.

Romney and his new running mate, Congressman Paul Ryan, have ignited a fierce political debate over Medicare because of Ryan's congressional budget proposal to privatize Medicare by giving senior citizens medical vouchers. The amount of those vouchers, Yglesias says, would be limited by a cap on Medicare spending growth equal to annual GDP growth rate plus 0.5 percent.

Obama has blasted the Ryan voucher plan, predicting it would "end Medicare as we know it." However, Yglesias says Obama in his 2013 budget proposal also seeks to limit growth in Medicare spending, using the same formula as Ryan.

Wyden Walks Medicare Policy Tight Rope

His Medicare reform white paper co-authored with GOP presidential running mate Paul Ryan has Democratic Oregon Senator Ron Wyden in the political crosshairs of just about everybody.Democratic Oregon Senator Ron Wyden, who isn't even on the ballot this fall, nevertheless finds himself in the middle of a hard-fought, negative presidential campaign. And he isn't happy about it.

Wyden co-authored a provocative white paper on Medicare reform options earlier this year along with House Budget Chair and now GOP presidential running mate Paul Ryan. The Mitt Romney-Ryan campaign seized on the white paper — and Wyden — as evidence of bipartisan support for their approach to Medicare reform.

Wyden has gone to great pains, including a speech this week to the Portland Rotary, to say ‘no dice.’

Defending the white paper and his collaboration with Ryan, Wyden says what Romney has endorsed and House Republicans have passed is not consistent with the white paper's approach to "preserve the Medicare guarantee."

In an interview with Ezra Klein of The Washington Post, Wyden said the major differences between his views and those of Romney involve the Affordable Care Act and Medicaid. Romney and Ryan favor repeal of the Affordable Care Act and Wyden doesn't. The Ryan-inspired House budget would give states more freedom to run their Medicaid programs for low-income citizens, but also provide less money. Wyden says that will harm lower-income seniors who qualify for both Medicare and Medicaid.

Health Care System in Limbo

Supreme Court justices may have more to weigh than just the constitutionality of the Affordable Care Act.If the U.S. Supreme Court finds the federal health care reform act unconstitutional later this year, experts say it could unravel more of the nation's health care system than anticipated, including Medicare.

Judy Feder, a former Clinton administration official, tells NPR's Julie Rovner that the push toward more integrated and coordinated health care delivery would be disrupted.

Gail Wilensky, who ran Medicare and Medicaid programs for President H.W. Bush, says voiding federal health care reform would erase the most recent benchmarks for doctor and hospital payment rates. 

"Hospitals might not get paid. Nursing homes might not get paid. Doctors might not get paid," Wilensky says. "Changes in coverage that have begun to take effect for the elderly, such as closing the donut hole, might not happen." The effects, she adds, would undoubtedly spill over to everyone in the health care system.

Sara Rosenbaum, a professor of health law, likens it a train wreck. "We could find ourselves at a grand stopping point for the entire health care system." One problem she cites is the possibility of thousands of Medicare policies being suddenly null and void.

Two Nerds, One Big Idea

Republican Paul Ryan (left) and Democrat Ron Wyden ignited a political firestorm in Democratic circles by jointly proposing a Medicare reform plan with private-sector involvement.Compromise and election-year messaging are often lightning bolts streaking in opposite directions. Congressional Republicans, intent on uprooting President Obama from the White House, have felt the tension. And so has Oregon Senator Ron Wyden, who teamed with House Budget Chair Paul Ryan on an improbable proposal to reform Medicare.

Congressional Republicans buckled to election pressures as they agreed to a compromise last week to extend a payroll tax cut, continue jobless benefits and block a Medicare fee cut to doctors.

But Wyden has no reason to buckle. A Democrat, he was re-elected comfortably in 2010 and remains one of Oregon's most popular political figures, in part because he is willing to work across the political aisle. Seeking bipartisan solutions on controversial issues is viewed today as the act of a political maverick in much the same way as Senators Wayne Morse and Mark Hatfield opposing the Vietnam War.

The Potomac Watch column in the Wall Street Journal ran a piece describing what it called the Democratic establishment's "War on Wyden” for his Medicare collaboration with Ryan. It noted New York Times columnist Paul Krugman called Wyden a "useful idiot" to Mitt Romney's presidential election bid. House Democrats, according to WSJ, "hissed the plan would end Medicare as we know it." And a former Senate staffer complained Wyden undercut a key argument for Democrats regaining control of Congress.

The Super Secret Committee

The Super Committee has a lot riding on its shoulders, but so far the horse hasn't left the barn. Photo by Kelly Canfield.The 12-member congressional Super Committee has until Thanksgiving to come up with another $1.2 trillion in federal spending cuts. Since it deliberates behind closed doors, no one really knows whether it is making progress or spinning its wheels.

So the best you can do is look for clues. One top House GOP lawmaker suggested the $1.2 trillion in savings could come entirely from health care reductions.

Congressman Denny Rehberg, R-MONT, who chairs the House Appropriations subcommittee that deals with health care spending, said the savings could be achieved with two simple modifications to the federal health care reform law adopted last year. One change would knock out proposed Medicaid expansion; the other would trim subsidies to help people buy health insurance.

At the same time, the Wall Street Journal reported that nearly 50 percent of Americans live in households that receive some form of federal aid. Almost 35 percent are in households receiving food stamps, subsidized housing, cash welfare or Medicaid benefits. Almost 15 percent receive Medicare benefits and nearly 16 percent receive Social Security benefits.