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Healthcare Costs

There may be no area of federal policy that significantly impacts more Americans than steadily rising health care expenses.  The country’s urgent need to rein in rising healthcare costs has resulted in a rare outpouring of recent bipartisan efforts to find practical solutions that can attract support beyond the base of one party or the other.  Today, there is an unusual window of opportunity for serious action that could meaningfully help the American people.  The Problem Solvers Caucus in the House is leading one of the most impressive bipartisan efforts in collaboration with Senator Susan Collins (Republican-Maine) and Democratic Senator Joe Manchin (Democrat-West Virginia).  We have discussed with Problem Solvers Caucus leadership and staff the possibility of applying CommonSense American’s approach to their efforts on healthcare costs.  They have expressed a keen interest in us choosing this as one of our three topics.  In fact, we have been invited to meet with the full caucus of 24 Democrats and 24 Republicans.

Two areas of focus appear particularly promising.  The first is prescription drug costs.  The second is surprise medical billing.

Controlling Rising Prescription Drug Costs

Prescription drug prices are hitting Americans particularly hard.  The average American now spends approximately $1,200 per year on their medications.  It also turns out that it is an area where several practical solutions are attracting serious bipartisan support.  President Trump has made this a top priority and has proposed concrete measures that rise above the typical partisan approaches.  The focus of the Problem Solvers Caucus, in cooperation with Senators Collins and Manchin, is on prescription drug prices.  So is the focus of a proposal by Senator Lamar Alexander (Republican-Tennessee), who chairs the Senate Health Committee and Senator Patty Murray (Democrat-Washington), the Ranking Member on that committee.  Similar bipartisan proposals have been offered by the House Ways and Means and by the House Judiciary Committees.

Several themes run through the prescription drug cost proposals attracting bipartisan support.  They focus on requiring greater transparency from manufacturers about drug costs.  Many of the proposals focus on eliminating obstacles to fair competition, particularly providing access to lower cost generic drugs.  Several proposals address what many consider to be abuse by drug manufacturers of their patents.  For example, some drug manufactures, once one of their profitable patents expire, pay potential competitors not to manufacture generic versions so that they can continue to charge higher prices.

Limiting Surprise Medical Billing 

Many patients are surprised by extraordinarily high emergency room visit costs.  Unexpected high costs can happen particularly when hospitals use out-of-network specialists, clinicians, or ambulatory services even though the hospital itself is in-network for the patient’s insurance provider.  Under current law essentially no legal limits exist to what patients can be charged for these out-of-network services.  Even though patients believed that all the care was in-network, were not informed that they would be personally responsible for thousands-of-dollars in costs, and did not consent to the use of out-of-network clinicians (often because they were unconscious or otherwise incapacitated), the patients are still legally obligated to pay the surprise bills.  If they are unable to pay them, they often face debt collectors and legal action.

President Trump has ordered an examination of the issue and several bipartisan bills have been introduced in Congress.  Possible solutions include set rates (usually based on Medicare or Medicaid payment rates), an arbitration process where a neutral arbiter would decide on a reasonable hospital bill, and transparency efforts that make sure patients who are in the hospital for longer stays understand the costs of their care and are provided options.

Many of the prescription drug price proposals also include these provisions to control surprise medical billing.  For example, the Problem Solvers Caucus is including surprise medical billing in their work.  The proposal by Republican Senator Alexander and Democratic Senator Murray also addresses surprise medical billing.

College and Professional/Technical Training Accessibility

Several practical proposals to increase the accessibility of college and professional/technical training are attracting bipartisan support.  The unusual agreement across the partisan divide is in part a response to the trend of the rich getting richer while everyone else benefits little from economic growth, a trend that has continued for 40 years through both Republican and Democratic control of the White House and Congress.  Bipartisan support is growing for some approaches to increase accessibility for additional education or training after high school because they create more opportunity without resorting to politically charged measures that redistribute wealth.  Give someone a fish, as the saying goes, you feed them for a day.  Teach them to fish, as both Republicans and Democrats recognize, and you feed them for a lifetime.

Making Pell Grants Eligible for Professional and Technical Training

Since World War II, the United States has adopted policies that encourage more people to go to college.  Three factors, however, have contributed to a growing recognition that shorter format professional and technical education can also play and important role in the lives of many Americans and the nation’s economy.  First, there’s an increasing awareness that college isn’t for everyone.  Many modern careers that are rewarding financially and professionally don’t require college but do require training past high school.  These careers include occupations as a plumber, electrician, truck driver, or automotive repair technician.  They also include health professionals like certified nursing assistants and surgical technicians.  The rapidly increasing demand for IT professionals is another example.  Second, the rising costs of four-year college degrees saddle students with sometimes overwhelming levels of debt.  Third, the demand for well-trained professionals in many of these areas are going unmet, stifling economic growth.

Many argue that our policies now need to change to provide the kind of support for professional and technical education that college has historically received.  The most prominent proposal to do this is the Jumpstart Our Businesses by Supporting Students (JOBS) act, cosponsored by Senators Rob Portman (Republican-Ohio) and Tim Kaine (Democrat-Virginia).  The JOBS Act would extend Pell grant funding to credit and non-credit programs that are shorter format than college degrees, are aligned with local labor market needs, and lead to credentials recognized by employers and approved by state authorities.  Pell grants provide federal support for students that doesn’t have to be repaid.  Eligibility is based on financial need and education cost, with the maximum grant currently at $6,195.

Making Pell Grant Eligible for High School Students with Dual Enrollment in College Courses

 Students have increasing opportunities to enroll in college courses while still in high school.  At many high schools, there are opportunities to enroll in courses at local colleges while also taking courses at their own high school.  Some students even enroll in early college high schools, where they take all of their courses at a local college while attending dances and games at their regular high school.  By earning college credit prior to graduating from high school, dual enrollment and early college high schools make a college degree more accessible.  Facing less time and expense to get one, more are able to attain a college degree and do it with less student debt.

The Go to High School, Go to College Act would expand these opportunities, particularly for low-income students.  Sponsored by Senators Rob Portman (Republican-Ohio) and Mark Warner (Democrat-Virginia) and by Representatives Marcia Fudge (Democrat-Ohio) and Chris Gibson (Republican-New York), the act would make dual enrollment and early college high school courses eligible for Pell grants.


Since the 9/11 attacks in 2001, more than 2 million members of the armed forces have deployed overseas to serve their country.  More than 52,000 have been wounded in action.  As of July 4, 6,987 had lost their lives.  Several proposals would recognize the sacrifice of those who return home with more than the words, “thank you for your service.”  Based on a recognition that our veterans should be last to be left behind in today’s economy, these proposals aim to address their economic opportunities and challenges.

Making Good on the Promise to Forgive Student Loans for Disabled Veterans 

Over 25,000 veterans who are totally and permanently disabled have defaulted on their student loans.  This circumstance is particularly troubling since existing federal law makes them eligible student loan forgiveness.  The existing law was passed with strong bipartisan support because of broad recognition that someone should not face the serious financial consequences of defaulting on a student loan when the reason they cannot pay it back is a disability suffered in service to our nation.

The proposed Federally Requiring Earned Education-Debt Discharges for Veterans (FREED Vets) Act would require the US Department of Education to automatically discharge federal student loan debt for those disabled veterans who are eligible.  This would address the current difficult red-tape that is causing tens-of-thousands of vets to default.  The FREED Vets Act was introduced just a few weeks ago in the House of Representatives by Representatives Conor Lamb (Democrat-Pennsylvania and Vice Chair of the Veterans Affairs Committee), Brian Fitzpatrick (Republican-Pennsylvania), Joe Courtney (Democrat-Connecticut), and Andy Levin (Democrat-Michigan).  A companion Senate version has also been introduced by Senators Jonny Isakson (Republican-Georgia), the Chairman of the Veterans Affairs Committee, and Jack Reed (Democrat-Rhode Island), the Ranking Democratic Member of that committee.

Creating More on Economic Opportunity for Vets by Reorganizing Veterans Affairs

The Department of Veterans Affairs (VA) is comprised of three administrations.  The first is focused on health care.  The second administers the national cemeteries.  The third focuses on a variety of benefit and aid programs available to veterans.  The Veterans’ Education, Transition, and Opportunity Prioritization Plan (VET OPP) Act would break up this third area of benefit programs into two separate administrations, one continuing to focus on disability claims and a new one called the Economic Opportunity and Transition Administration, focused on education, the GI Bill, job training, and transition assistance.

Senators Marco Rubio (Republican-Florida) and Maggie Hassan (Democrat-New Hampshire) and Representatives Mike Levin (Democrat-California), Brand Wenstrup (Republican-Ohio) introduced the bill because the benefits administration spends most of its efforts on disability claims, neglecting job training assistance.  While the legislation wouldn’t add significant new resources, advocates argue that a new, senior executive and a high-level staff will increase accountability within government and visibility of the VA’s transition benefits and aid outside of government.

Upward Mobility Generally

Other bipartisan measures are emerging that aim to expand economic opportunity beyond those aimed specifically at professional/technical and college education or veterans.

Protecting Against State Government Stripping Americans’ Occupational Licenses

More than a dozen state laws give states the authority to revoke a person’s professional, occupational, or driver’s license when they fall behind on their student loans.  The Protecting Job Opportunities for Borrowers (Protecting JOBs) Act would make it illegal for states to do that.  Senators Marco Rubio (Republican-Florida) and Elizabeth Warren (Democrat-Massachusetts) jointly introduced the legislation because, they argue, removing a person’s source of income makes repaying the loan, as well as providing for his or her family, even more difficult. The bill does not prevent states from revoking licenses for unsafe practices or any other reason.

Incentivizing Work by Expanding the Earned Income Tax Credit for Workers without Children

 Many Democrats and Republicans share an interest in encouraging work and making it easier for low-income wage earners to make ends meet.  They often disagree, however, on the best means for doing that.  Many Democrats support an increase in the minimum wage or various mechanisms for redistributing wealth.  Many Republicans oppose increasing the minimum wage because, they argue, it will actually hurt job prospects for those with the least amount of education and workforce skills.  Many jobs will go away, the argument goes, because businesses will no longer be able to afford them.  Many Republicans also oppose wealth redistribution, arguing that while policies to make economic opportunity more equal can be appropriate, equalizing economic outcomes is not.  Taking money from the rich and giving it to others, even when their own choices have contributed to their economic challenges, some Republicans argue, is unfair and counter-productive.

There is a different approach that has attracted bipartisan support even though its name is a real sleeper.  Former Republican Speaker of the House Paul Ryan was an early advocate of incentivizing work by expanding the Earned Income Tax Credit (EITC).  The EITC was originally created to address a disincentive for many low-income workers to work more.  Because many low-income workers paid little to no income tax, they faced a disincentive to work more because it would result in having to pay income taxes.

The EITC provides a refundable credit for workers with low and moderate incomes.  That means that, at certain levels, they can get a check back that’s more than what they paid in income taxes.  As a worker’s incomes rise, the credit flattens out and then declines, to reduce disincentives to work.  Many Republicans and Democrats agree that the EITC has been successful for workers with children.  However, the EITC provides much lower benefits for low and moderate income workers without children.  Former Speaker Ryan as well as a range of liberal leaning legislators think tanks have argued that EITC benefits for workers without children should be expanded.


The United States has fallen chronically far behind in meeting its needs for infrastructure, including the electrical grid, our water systems, and transportation infrastructure like roads, freeways, bridges, airports, and ports.  Most estimates peg the total cost of catching up to be well over $1 trillion.  President Trump, as well as Democrats and Republicans in Congress, support addressing the problem for at least two reasons.  First, we would all benefit in our daily lives from addressing our deteriorating infrastructure.  We would spend less time in traffic, drive roads with fewer potholes, and have access to electricity and water that is more reliable and environmentally friendly.  Second, improving our infrastructure boosts the economy.  More efficient and reliable infrastructure make all aspects of the economy function better and the infrastructure projects create jobs.

Despite the compelling rationale for infrastructure improvement and bipartisan support, it has still proven difficult to pass legislation that would significantly increase funding for infrastructure.  In part, the challenge is that the federal government is already spending far more than it’s taking in.

Consequently, there has been a bipartisan effort to find smaller bore, alternative solutions that, while not fully addressing the infrastructure funding needs, would provide meaningful help without significantly increasing the deficit.

Speeding Up Permitting Time

It takes an enormously long time to get the permits for infrastructure projects, often 10 years or more.  This adds significantly to the cost of these projects.  One analysis found that a six-year delay in permitting doubles the cost of a project.  The US is unique in its extraordinarily long permitting times.  Much of the delay comes from the delays caused by the unique way that the US approaches review of the environmental impacts of a project.  While US standards on environmental impacts are not more stringent than many other developed countries, for example in Canada and Western Europe, the length of our process for review of those impacts is several times longer.  These long environmental review processes can actually cause environmental damage by delaying environmentally beneficial infrastructure upgrades, in addition to increasing costs significantly.  For example, America’s outdated electrical power grid wastes 200 coal burning plants’ worth of electricity.

Republicans and Democrats have successfully come together to speed up the permitting process.  In 2015, Congress passed legislation to streamline the permitting process in a variety of ways without reducing environmental standards and President Obama signed it into law.  President Trump has also argued that we should do more to speed up permitting times.  While the 2015 legislation has been successful in many ways, it took several years to implement and will sunset in December 2020.  Senators Rob Portman (Republican-Ohio) and Claire McCaskill (Democrat-Missouri), who together drafted the original provisions, have drafted new legislation that would make these provisions to speed up permitting time permanent.

Expanding Smart Tools for Financing Infrastructure

A variety of bipartisan proposals aim to increase funding for infrastructure significantly without increasing the federal deficit significantly through smart financing tools.  Because the benefit of most infrastructure projects will last 30 years or more, but the costs to build them are incurred up front, many infrastructure projects are funded through bonds.  Typically, the government sells bonds to private investors who are payed interest on the bonds.  These bonds attract private investors for two reasons.  First, they provide a safe, government-backed way of getting a return on one’s investment.  Second, the interest paid to investors on these bonds is tax free.

Several proposals would generate additional private dollars for infrastructure by expanding existing bond limits.  Senators John Hoeven (Republican-North Dakota) and Ron Wyden (Democrat-Oregon) and Representatives Earl Blumenauer (Democrat-Oregon) and Jacki Walorski (Republican-Indiana), for example, have proposed the Move America Act.  The $8 billion in federal investment could unlock $226 billion.  It would do this by expanding the use of Private Activity Bonds, which can be issued for public-private partnerships or even private entities undertaking an infrastructure project with a public benefit.  Because of this private aspect, interest payments on Private Activity Bonds aren’t completely tax free like typical government issued bonds.  The Move America Act would make Private Activity Bond interest payments fully tax free and would raise the limits on how many can be issued.


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