Medicare-For-All (M4A) is gaining some steam. Two prominent Democratic candidates for the presidency, Senators Elizabeth Warren and Bernie Sanders, support it, and several polls show that the idea is supported also by a majority of Americans.
In recent days, two academics from U.C.-Berkeley have even argued that a transition to M4A from the current system would dramatically cut taxes for the majority of workers by replacing all insurance premiums with taxes based on ability to pay.
That outcome sounds great until you ask how we will pay for it. According to a new study by the Urban Institute, M4A will cost $32 trillion over ten years. This estimate is in line with that of my colleague Charles Blahous. That’s more than the federal government will be projected to pay over the coming decade for Social Security, Medicare, and Medicaid combined, according to the most recent Congressional Budget Office projections. According to Urban, you could reduce the damage down to $16 trillion with some cost sharing and some limits on benefits. Either way, that’s a lot of money.
As Brian Riedl notes recently, one of the ideas floating around is that we simply need to come up with a $35 trillion tax to pay for it all (I am not kidding). He writes, “Proponents [of M4A] assert that the $35 trillion that families and businesses are currently projected to pay over the next decade in health premiums, out-of-pocket expenses, and state taxes to fund Medicaid would all be replaced with a $35 trillion federal ‘single-payer tax….”
Yet we have no details of how that would work in practice, and no one who supports M4A so far has offered an actual plan for the elusive $35 trillion replacement tax. Riedl writes, “Congressional Budget Office data show that raising $35 trillion would require a payroll tax increase of 39 percentage points, or a value-added tax of 91 percent – an enormous burden even for families no longer paying premiums.”
The scale of the tax hike it would require probably explains why no one wants to talk about it seriously. During the last Democratic debate, Senator Sanders acknowledged that it would require raising taxes on the middle class. He said, “At the end of the day, the overwhelming majority of people will save money on their health care bills. But I do think it is appropriate to acknowledge that taxes will go up.” But he has failed to give us any details about which taxes will go up and by how much and his campaign has only pointed out some options to pay for part of this extra government spending.
Meanwhile, Elizabeth Warren has vehemently refused to say if the middle class would see its taxes go up to pay for M4A or how she would pay for this. As the Wall Street Journal reported, for instance, during the debate Ms. Warren, the new leader in the polls, was given at least six chances to answer yes or no. She ducked every time. “Will you raise taxes on the middle class to pay for it, yes or no?” asked one of the media questioners.” The Journal continues, Ms. Warren replied: “So I have made clear what my principles are here, and that is costs will go up for the wealthy and for big corporations, and for hard-working middle-class families, costs will go down.” Later on she added, “Costs are going to go up for the wealthy,” and “costs will go down for hard-working, middle-class families.”
Got it; costs will go down for some and costs will go up for others. Yet we still have no clue just who will pay for what and how much the bill will be. Even those Berkeley professors won’t tell us how to pay for it. They have mentioned having a plan for some taxes as replacement of the cost of the employer side of insurance premiums. But, if this was even doable, it may raise between $10 trillion to $18 trillion (depending on how you measure it) of the $32 trillion.
While Warren doesn’t want to talk about, we can still do the calculation for her. For one thing, she has been open about paying for all her new spending ideas with a wealth tax on the rich, a corporate surtax, an increase in the estate tax, and the elimination of President Donald Trump’s tax cuts. Her wealth tax would raise, she claims, $2.75 trillion over ten years. Reversing the tax cuts would raise revenue by another roughly $2 trillion over ten years. You can add to that another $3 trillion that her campaign says she will raise through other taxes on the rich.
However, once you spend $32 trillion on M4A, $1.07 trillion for universal childcare, $610 billion for free college, $640 billion for eliminating student debt, $100 billion to combat the opioid crisis, and some other smaller programs, you are still left with a $30 trillion gap.
That’s 30,000,000,000,000 over ten years. It also ignores the deadweight losses of all this spending and new taxes on top of their inability to truly raise as much revenue as planned.
The bottom line is this: while M4A is getting a lot of favorable attention these days, proponents will continue to tout the benefits of a reform that lowers costs for some, while staying as far as they can from actually proposing a way to pay for it. But as PJ O’ Rourke famously said, “If you think health care is expensive now, wait until you see what it costs when it’s free.”