Sens. Elizabeth Warren, D-Mass., and Bernie Sanders, I-Vt., are running on a multitrillion-dollar plan Sanders wrote to provide health insurance coverage to all Americans through the federal government, rather than from private insurers. Although they have frequently stressed that the middle class would see overall costs go down, a wide range of experts - including one whom Sanders has relied upon - say it is impossible to make those guarantees based on the plans that the candidates have outlined so far.
"Obviously, all of the 180 million people who have private insurance are not going to pay less. It's impossible to have an 'everybody wins' scenario here," said Kenneth Thorpe, chairman of the health policy department at Emory University. "The plan is by design incredibly disruptive. As a result, you create enormous winners and losers."
"There's no question it hits the middle class," he added.
John Holahan, a health policy expert at the nonpartisan Urban Institute agreed: "Even though high-income people are going to pay a lot more, this has to hit the middle class."
Several other economists who specialize in health care say it is difficult to predict how most Americans would be affected, given far-reaching impacts on the nation's two most complicated systems, health care and taxes. They include one to whom the Sanders campaign referred The Washington Post.
Robert Pollin, a professor at the University of Massachusetts at Amherst who has consulted with Sanders, said he has been baffled by how the senator from Vermont talks about the proposal and says there are not enough details to analyze how the middle class would be affected.
"I didn't try to decipher. Theirs was too complicated," he said. "They don't go into a whole lot of detail. . . . The Sanders proposal to me was not clear enough to enable me to make the estimates on different types of families."
Their skepticism comes as voters are seeking more assurances at town hall meetings and as former vice president Joe Biden focuses more tightly on his plan to build on President Barack Obama's health-care law with a proposal that costs far less than the one from his two key rivals. New polling has also shown some of the political risks of Medicare-for-all, with voters growing more skeptical once they learn of the details.
After questions were posed over the past few weeks, the campaigns conceded that their plans remained in flux. They put forward several new arguments and provided additional detail in their cost estimates, but their responses did not fully answer a key question: In a plan that would significantly alter the tax code and the health-care industry, how many and which Americans would ultimately be hit with higher costs?
The Sanders campaign said it would be able to address that question with more precision after it releases a comprehensive plan on reforming the nation's tax laws. It would not specify when that plan would be released.
Health care has dominated the first three debates and promises to factor heavily into the next one, on Oct. 15. The once largely philosophical debate about whether Americans should have a choice of insurers is turning toward more fundamental and specific questions about how much it would cost and who would pay for it.
Long confined to the fringes of the Democratic Party, Medicare-for-all has become more popular in recent years, helped along by the rise of Warren and Sanders. Now, in the eyes of many voters, the burden for explaining the nuts and bolts of the plan has fallen upon the candidates.
"Medicare-for-all does appeal. It's just how we're going to pay for it," said 37-year-old Yul Owens of Philadelphia, who attended an AFL-CIO candidate forum last month. "As long as somebody has a plan for how we're going to fund these things, there's not a problem at all."
But the candidates' plans don't fully explain the funding. Sanders has said his plan would be paid for in part with higher middle-class taxes, something that Warren has declined to directly acknowledge. They both make the case that any tax increases would be offset by health-care savings.
"If you're making more than $29,000, in a progressive way, you will be paying more in taxes," Sanders said in an interview conducted before his recent hospitalization. "But the increased taxes that you're paying will be significantly less than what you were paying for premiums, co-payments and out-of-pocket expenses."
Yet, in the way Sanders has outlined his proposal, that statement won't apply to everyone. And his campaign has been unable to say at which income level Americans would start paying more in taxes than they would save in health-care costs.
The Sanders campaign has sought to frame the debate over Medicare-for-all in personal terms, emphasizing how it would address the catastrophic financial toll health-care costs have taken on some Americans under the current system. He touted the plan repeatedly while being treated for a heart attack, noting that such sudden illnesses as his can be financially ruinous for those without coverage.
Warren, despite a reputation for coming up with plans on a wide variety of subjects, has so far largely outsourced her health-care proposal to Sanders. "I'm with Bernie," she said at the first debate, signaling to fans of his plan that they would also have a champion in her.
Warren has been pressed in a variety of settings - on debate stages, in interviews, on late-night television shows - but has avoided the question of costs to the middle class. MSNBC's Chris Matthews asked her the question in late July several times without an answer, to the point that he said in frustration, "I'm not getting anywhere."
When asked specifically how she would finance Medicare-for-all, Warren's campaign said she is "reviewing the options" suggested by Sanders and is also examining "other options" for how to pay for the plan. Her campaign would not outline what that entails.
The campaign pointed to Warren's previous statements pledging not to raise overall costs on middle-class families but would not outline how she would accomplish that with a plan that many economists, as well as Sanders, say will require significant tax hikes.
"Right now, what we've got in Medicare-for-all is a framework, and it doesn't have the details," Warren said late last month in Keene, New Hampshire, responding to a voter worried about losing his health care.
She also floated the idea of offering "cash equivalents" to union members who lose favorable insurance plans that have been negotiated during the transition to Medicare-for-all. (Sanders also has proposed assistance for those workers.)
Sanders estimates that his plan would cost $30 trillion to $40 trillion over 10 years. But his campaign clarified that - because he would use the spending already going toward Medicare, Medicaid and other health-related government programs - he would only need to come up about $15 trillion in new revenue.
He has proposed several tax increases to help pay for it, all of which add up to $16.2 trillion. Those details are crucial to projecting how an average American family might be affected by the transition to Medicare-for-all.
A portion of the revenue for Sanders's plan would come from an additional 4 percent tax on income for families making more than $29,000, which he estimates would raise $3.5 trillion. He would also impose an additional 7.5 percent payroll tax, raising $3.9 trillion. Although Sanders would levy the payroll tax only on employers with payrolls over $2 million, economists generally assume that all payroll tax increases are passed along to workers in the form of wage cuts, slower wage increases or job losses.
The senator has proposed generating further revenue by making more affluent Americans pay more in taxes, including raising the top marginal tax rates, limiting itemized deductions and establishing a wealth tax.
Sanders has argued that his plan would be cheaper than maintaining the status quo - putting forward a $50 trillion figure to maintain current health-care spending over the next 10 years - but fact-checkers have said that figure is dubious.
Sanders also has provided estimates for a family of four earning $50,000. He estimates that the family would no longer pay $5,277 in premiums and would see their taxes go up by $844 - seeing a savings of about $4,400. The employer, instead of paying $12,865 a year in health-care premiums for the family, would have a payroll tax increase of $3,750 - for a savings of $9,000.
But the employer would break even if the insured is an individual making $50,000 - rather than a family of four, which has higher premiums - according to The Post's Fact Checker. The financial impact on an individual would depend on whether the employer passes on the additional costs they could incur on employees making above $50,000.
Sanders and Warren have declined to specify what they view as "middle class" - something Pew Research Center puts at $45,200 to $135,600, based on 2016 data - but economists say that most taxpayers would pay more in taxes than they would save from having the federal government absorb the cost of health-care premiums.
Thorpe's analysis of the Medicare-for-all plan that Sanders outlined in 2016 found that about 71 percent of those with private insurance would pay more in new taxes than they would save by having health insurance covered by the federal government. Thorpe estimated that Sanders's plan is underfunded and would need higher taxes than he has proposed; Sanders's updated health-care plan, released this year, would impose higher taxes than his earlier proposal but still not as high as Thorpe says would be needed.
"Most of the proposals to move to Medicare-for-all would involve substantial tax increases that would affect most people," said Katherine Baicker, an economist at the University of Chicago who specializes in health policy. "These are going to be big tax increases. The tax brackets may have to shift. You may have to do more than just dialing up the top tax bracket in a realistic accounting."
"I think it seems likely under most proposals taxes would have to go up substantially unless you dramatically cut the health care you're getting," she added. "And I don't think most proposals envision substantially cutting back on care. And most envision expanding care, which means you're spending more unless you dramatically cut the price per service."
Pollin,the professor who has briefed the Sanders campaign on his plan, said his in-depth study of how Medicare-for-all would work was paid for by National Nurses United, which has backed Sanders and supported Medicare-for-all. Pollin briefed the campaign, and Sanders himself, on his findings.
Pollin said he believes the goals are achievable and has come up with a different proposal to pay for the plan that he says would ensure that low- and middle-class Americans would not see overall costs go up. But that is not the same as Sanders's plan.
Biden has proposed adding a public option that would allow people to choose between a private insurance plan or one offered by the federal government. His plan would cost an estimated $750 billion, which he would pay for by repealing the tax cuts for the wealthy that were passed in 2017 and by raising capital gains taxes.
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