Elizabeth Warren has published a plan to pay for Medicare for All and her plan is full of fantasy math which, once it collides with reality, won’t come close to covering the cost. Today, the Wall Street Journal published an editorial spelling out a few of the problems:
Start with the overall fiscal math, which by itself is staggering. She concedes that her plan will cost only “slightly” less than the $52 trillion that the U.S. is expected to spend on health care in the next 10 years. She deducts from that what the feds now spend on Medicare and Medicaid, plus $6 trillion that the states contribute to Medicaid, the state-federal children’s health program and government worker benefits.
That leaves $30 trillion to finance, but Senator Warren waves her wand and says the bill will really be $20.5 trillion. She makes the rest vanish by positing magical savings from things like “comprehensive payment reform.” One of her ideas is the hardy perennial known as “bundled payments,” which have failed to reduce costs as promised by Obama Care.
Over at Reason, Peter Suderman has a bit more on the planned savings from bundled payments. It turns out that there’s pretty good research suggesting they won’t save any money at all:
The bulk of Warren’s presumed savings in this area—about $1.2 trillion—come from increasing the use of “bundled payments.” Bundled payments, in which health care providers are paid as a sort of package deal rather than on a fee-for-service basis, were once a source of great hope for America’s health care wonks, the class of people who believe that the best way to reduce health care spending is through technocratic fixes that are often lumped together as delivery system reforms. Some early studies found spending reductions for hospitals that chose to participate, and initial projections by the Congressional Budget Office projected bigger savings down the road.
Yet as it turned out, there was a problem with those initial studies: They looked at hospitals that had chosen to participate, skewing the sample toward institutions where bundled payments were more likely to be effective. When a team of researchers from Harvard, Cambridge, Dartmouth, the University of Chicago, and the Massachusetts Institute of Technology—the sort of all-star academic lineup that a committed wonk like Warren ought to trust—were able to study data from a randomized sample, they found no significant overall savings, especially after program bonuses were factored in. Similarly, a study published by the fiscally conservative Commonwealth Foundation last year reported that “hospitals participating in Medicare’s most recent bundled payment initiative did not have lower costs or other better outcomes compared with hospitals not participating.” (Wonks need not fear: Delivery service reforms have not failed, they have just never been truly tried.)
Suderman notes she saves another trillion with some extremely optimistic accounting:
She assumes, for example, that health spending will grow at just 3.9 percent over the decade, far slower than the projections from either Medicare’s actuaries or the Urban Institute, a left of center think tank. With slower spending growth comes more than $1 trillion in savings she doesn’t have to pay for either.
We’ve already blown a hole in her plan that is much larger than the burgeoning annual budget deficit and we’re really just getting started. Lawrence Summers, writing at the Washington Post, says her plan to bring in more revenue by tougher IRS enforcement is also a fantasy:
Warren estimates the revenue potential of increased Internal Revenue Service enforcement as being about 65 times as large as the Congressional Budget Office’s enforcement proposal. The University of Pennsylvania’s Natasha Sarin and I have been working to make the case that the CBO is far too pessimistic in its estimates of the potential for better enforcement to generate revenue. But the most optimistic scenario we can envision is still more than $1 trillion short of the Warren estimate.
There’s also a significant problem with Warren’s doubling of the proposed wealth tax:
Warren’s plan would double the 3 percent tax on wealth over $1 billion that she has already proposed. Many experts believe the Warren wealth-tax revenue estimates are too high, perhaps by a factor of two, because they overestimate the wealth of the very rich and, as Sarin and I have argued, underestimate potential avoidance. Whatever the merits of these arguments, it is hard to see a defense for assuming — as the Warren proposal does — that wealth taxes can be doubled with no impact on avoidance, or that annual capital gains taxes can be levied without reducing the wealth tax base.
In other words, this doesn’t make much sense:
The initial Warren 2% wealth tax assumes 15% avoidance.
Today's 6% proposal also assumes 15% avoidance.
— Natasha Sarin (@NatashaRSarin) November 1, 2019
If you double the wealth tax, avoidance will increase and the amount of revenue that comes in will decrease. Looking over all of this, even Vox’s Ezra Klein doesn’t find it very convincing (though he’s still rooting for her):
There are places where I find Warren’s math or ideas a bit optimistic. I’m skeptical that payment reforms will save trillions. I think you can move the system to a lower price structure, but it probably has to happen slowly, gradually, which will jack up the initial cost of the plan. I suspect Medicare-for-all will be harder to administer than Medicare is now, particularly in its early years. The unintended inequities of her employer financing plan seem like both a political and practical problem. If you’re going to cut drug prices that dramatically, at least some of the money should be used to boost innovation in a targeted, sustained way — we want drugs to get better, not just cheaper. And no one really knows how quickly health spending will grow.
The WSJ editorial board concludes, “Donald Trump’s boast that Mexico would pay for the wall was more believable.” Finally, I think Suderman at Reason nails it when he says Warren hasn’t really come up with a plan to pay for Medicare for All she’s come up with a plan to claim she has a plan: “Warren has enlisted a legion of implausible savings mechanisms and unworkable tax hikes in hopes of cobbling together something that looks convincing from afar.”
Warren sells herself as a wonk but she’s really acting as a magician. She hopes that if she waves her hands enough, Americans will let her pull a single payer rabbit out of a hat without thinking too hard about how it got there. By the time people realize they’ve been tricked, it’ll be too late. The middle class will simply have to start paying the massive new taxes Warren promised would never come. Warren’s plan amounts to “If you like your current taxes, you can keep them.” Like Obama, she’s lying.