After dodging repeated questions from interviewers and in the recent Democratic debate as to how she is going to pay for Medicare-for-all, Sen. Elizabeth Warren (D-Mass.) has promised she will look at how to pay for it. On Sunday according to CNN, she pledged, “I’ve been working for months and months, and it’s got just a little more work until it’s finished, but I want to bring this out.” She added, "I think there have been many estimates about what the cost will be, and many different payment streams, and I’ve been working on how to give the exact details to make that work.'

It will be interesting to see how the math works given that she has signed onto the enhanced Medicare-for-all plan advanced by Sen. Bernie Sanders (I-Vt.) but promised not to increase total costs for the middle class. (Total cost is a slippery concept, since some people use a lot of medical services and others do not. Would the total bill go up for middle-class workers who use health-care services only sparingly?)

Sanders has conceded that he would apply a 4 percent tax to everyone making at least $29,000 and would also enact a new 7.5 percent payroll tax, which would in part be shouldered by middle-class workers (if paid by the employer, it is reasonable to assume that the result would be lower pay for workers to account for the new expense). Beyond that, MarketWatch reports, “Sanders proposes a variety of progressive tax changes, including imposing a marginal tax rate of up to 70% on those making above $10 million, taxing earned and unearned income at the same rates, limiting tax deductions for filers in the top tax bracket, establishing a tax on extreme wealth and making the estate tax more progressive, including a 77% top rate on an inheritance above $1 billion.”

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The tricky part here is that Warren has promised that “costs” for the middle class will not go up and she has already put out a wealth tax to pay for all her other programs (e.g. child care, free college), so that money cannot be double-counted.

Fortunately, the progressive Urban Institute recently put out a study on various health-care plans. The kind of enhanced single-payer plan Sanders and Warren are talking about includes “eliminating all cost-sharing requirements, adding additional benefits for adult dental, vision, and hearing care and LTSS [long-term services and supports]. Because the single-payer (or Medicare for All) proposals currently being discussed would provide coverage to undocumented immigrants, we include all US residents in these estimates." The Urban Institute finds: “Net federal government health spending, accounting for savings from eliminating Medicare, Marketplace subsidies, the acute-care portion of Medicaid, and uncompensated care, as well as savings on other federal insurance programs, increases by $2.8 trillion in 2020. Offsetting increases in income tax revenue mean $2.7 trillion in additional federal revenue is needed to finance the new program.” That is for a single year. It does not include a calculation as to how much more in health-care services people will use when they are essentially free.

In short, the Urban Institute concludes that an enhanced Medicare-for-all program requires additional federal spending of $34 trillion over 10 years, a mere $32 trillion after tax offsets.

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Other analysts come to slightly different results. Kenneth E. Thorpe of Emory (who advised the failed Medicare-for-all program in Vermont) found that “the new federal revenues needed would exceed $32 Trillion over the next decade, Senator Sanders has himself stated that the Federal budgetary cost would be over $30 trillion over a decade.” Thorpe explained:

The Vermont version was a less generous version of Medicare for All (they retained cost sharing of 6 to 13 percent). However, the estimates produced by state and others found that it would require a 9.5 percent increase in income taxes and a new 11.5 percent payroll tax so overall a combined middle-class tax increase of 21 percent. A Medicare for All plan when fully implemented would require even larger tax increases given the elimination of all cost sharing. ... All of Sanders options together raise about $15 trillion over ten years – far short of the over $30 trillion he proposes to pay for this. He admits that there would be middle-class tax increases required but has not outlined what they are.

Even more troubling, “My recent analysis compares the dollars savings households with private health insurance would receive through the elimination of premiums and cost sharing to the new federal taxes they would pay to fund the program. The analysis shows that 71 percent of households with private insurance today would pay more in new taxes than they would save through the elimination of premiums and cost sharing.” And remember, Warren has already ruled out applying those taxes to middle-class Americans if it means their total cost goes up.

The middle class cannot escape scot-free. “For example, two-thirds of workers in small firms under 50 would pay more in taxes under a Medicare for All plan than they would save in the elimination of premiums and cost sharing,” Thorpe found. “The tax increases would also hit the middle class. Two-thirds of families of 4 earning $50,000 to $75,000 would pay more in taxes than they would save through a Medicare for All plan. Overall over 10 million households earning between 200 and 300 percent of poverty would pay more in taxes than they would save through the elimination of premiums and cost sharing. Overall nearly 70 million households would pay more in higher taxes than they would save under Medicare for All.”

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Then there are the job losses:

Medicare for All would also result in lost jobs. Medicare for All advocates point out that paying providers at Medicare rates and administrative savings would reduce what we spend on health care. That ignores the fundamental equation that expenditures equal income. For example, paying the over 5,000 community hospitals at Medicare rates would reduce their revenue by 16 percent and eliminate 1.5 million jobs. Hospitals are often the largest employer in many small and mid-size communities that reductions of this magnitude would have enormous economic and social implications for them. The elimination of private insurance would also result in lost jobs through the elimination of health insurance, by some estimates nearly 1 million in the health insurance industry.

Those workers include nurses, janitors, clerical workers, technicians and others in middle-class jobs.

Now, Warren prides herself on a plan “for everything” and for paying for everything, so I look forward to seeing her math. If single-payer didn’t work in Vermont and if foreign countries’ health plans are less generous and/or require some co-pays, Warren has her work cut out for her.

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