Six weeks ago, this publication published “Elizabeth Warren Has a Plan…For Avoiding Your Health Care Questions.” That plan came to fruition last Friday, when Warren released a paper (and two accompanying analyses) claiming that she can fund her single-payer health care program without raising taxes on the middle class.
Both her opponents in the Democratic presidential primary and conservative commentators immediately criticized Warren’s plan for the gimmicks and assumptions used to arrive at her estimate. Her paper claims she can reduce the 10-year cost of single payer—the amount of new federal revenues needed to fund the program, over and above the dollars already spent on health care (e.g., existing federal spending on Medicare, Medicaid, etc.)—from $34 trillion in an October Urban Institute estimate to only $20.5 trillion. On top of this 40 percent reduction in the cost of single payer, Warren claims she can raise the $20.5 trillion without a middle-class tax increase.
How does Warren arrive at her numbers, and how credible are they? The below analyzes every proposal and assumption in her plan: both those generating savings within the health-care system and those creating additional revenue to pay for single payer. All numbers below rely on Warren’s own 10-year estimates; she bases the savings figures on reductions in spending relative to the Urban Institute’s 10-year score.
One gimmick applies to all of Warren’s revenue estimates, and is buried on page 12 of the revenue appendix:
We have used static estimates to score the revenue measures used to fund your [single payer] plan. These estimates thus do not account for the impact of these revenue measures on economic activity.
In other words, if taxing “the rich” and corporations shrinks the economy—which it undoubtedly will—then Warren’s revenue forecast won’t meet projections, and she will have a huge, multi-trillion-dollar hole in her estimates. (Oops.)
Savings Proposal 1: Insurer Administrative Spending
How Much: $1.8 trillion, which comes from assuming the single-payer program will have an administrative cost rate of 2.3 percent—what the authors claim as Medicare’s current administrative costs at present—rather than the 6 percent assumed by the Urban Institute.
What’s the Catch? Claiming that single payer would rely on Medicare’s current administrative costs ignores one fundamental point: Contrary to claims by Warren and Sen. Bernie Sanders (I-Vt.) that their plan would create “Medicare for All,” Sanders’ legislation (which Warren has co-sponsored) would abolish the current Medicare program, and create an entirely new government-run health program—with an entirely new regulatory regime.
Federal bureaucrats would have to translate the 100 pages of Sanders’ bill into (tens of) thousands of pages of regulations and guidelines. This massive undertaking would increase rather than decrease Medicare’s administrative costs for many years to come. One analyst at the Urban Institute warned that the new government program “might not have the resources to do a good job at setting prices for vital services.”
Second, the supposed 2.3 percent rate of administrative costs for the current Medicare program omits major costs excluded from the trustees’ estimate—such as the costs of construction for Medicare’s buildings, or the collection costs that the Internal Revenue Service shifts to the private sector (e.g., employers’ administration of payroll taxes). In 2009, liberal writer Ezra Klein said “a more straightforward estimate” of administrative costs for Medicare “would be in the range of 5 to 6 percent”—the range assumed by the Urban researchers. He continued:
Some activities that are considered ‘administrative’ are useful. Disease management, for instance….Good-faith investigations into waste, fraud, and abuse. Care coordination. Nurses who use e-mail or telephones to remind patients to take their drugs. Administration is not always wasteful.
Particularly given current improper payment rates—8.12 percent for traditional Medicare, and 9.8 percent for Medicaid—keeping administrative costs arbitrarily low would discourage anti-fraud efforts in the new government-run program, representing a poor use of taxpayer funds.
Gimmick Factor (scale of one-to-ten): 10. In 2017, the fact checker for the Washington Post said “single-payer advocates are counting savings that might not materialize”—exactly Warren’s strategy. Furthermore, it appears ridiculous for Warren on the one hand to claim that greater enforcement of tax laws will generate additional revenue to fund single payer (about which more below), but on the other hand to claim that keeping administrative costs low will not encourage massive amounts of fraud in the new government program.
Savings Proposal 2: Prescription Drug Reform
How Much: $1.7 trillion in prescription drug savings, above and beyond the savings assumed by the Urban Institute, by assuming a 70 percent reduction in current Medicare prices for branded drugs, and a 30 percent reduction in current Medicare prices for generic drugs.
What’s the Catch? The plan assumes reductions well beyond the supposed savings in House Speaker Nancy Pelosi’s drug “negotiation” legislation (H.R. 3). It applies “negotiation” to all branded and generic drugs, reduces the target price for “negotiation” from 120 percent of the international average to 110 percent of that average, adds penalties for companies that raise the price of their drugs above the rate of inflation, and allows the federal government to license companies’ patents if they refuse to “negotiate” their prices.
As with the Pelosi bill, these proposals bring two problems. First, both Pelosi and Warren assume their legislation passes legal and constitutional muster, but it quite possibly does not. The Congressional Budget Office (CBO) noted in its preliminary score of Pelosi’s bill that the legislation “could result in litigation” on those grounds. Imposing an excise tax of up to 95 percent—which CBO noted “could cause the drug manufacturer to lose money” on their products—or licensing a company’s patents each raise legal issues regarding unconstitutional takings without proper compensation.
Second, imposing these types of price controls through government “negotiation” will decrease incentives for the development of new drugs. CBO concluded that H.R. 3 “would lead to a reduction of approximately 8 to 15 new drugs coming to market over the next 10 years.” Other analysts think the legislation could have a much greater impact in inhibiting new drug development.
Gimmick Factor: 7. Not for the first (or last) time, Warren presupposes that trifling inconveniences like the U.S. Constitution and the rule of law need not apply to her plan.
Savings Proposal 3: Lower Hospital Payments (Part I)
How Much: $600 billion in savings, above and beyond the savings assumed by the Urban Institute, by paying hospitals 110 percent of current Medicare rates, instead of the 115 percent of Medicare rates assumed by Urban. (Physician payments would total 100 percent of current Medicare rates in both plans.)
What’s the Catch? Warren’s plan contains four main assertions to support these lower payment rates, all of them dubious. First, she claims that enacting single payer would reduce providers’ administrative-related expenses (separate and distinct from insurers’ administrative expenses) by anywhere from 50-75 percent. As noted above, however, the uncertainty associated with creating an entirely new regulatory regime could well increase the administrative burden on doctors and hospitals for many years.
Second, Warren claims that single payer would lead to additional revenues: “Physicians would gain back much of [their] time for additional patient care, increasing their billable hours,” and “for hospitals, this increased access [to services] means increased volume and enhanced revenues.” By making this argument, Warren encourages doctors and hospitals to bill for additional services—even as the rest of her paper claims to want to move the health-care system away from traditional fee-for-service medicine. Moreover, as I argued more than a year ago, her argument essentially means doctors and hospitals will get paid less for doing more work.
Third, the paper claims that increased antitrust scrutiny will improve efficiency under single payer: “hospital competition will be an important feature…to ensure that providers are competing for patients on the basis of care quality and experience.”
However, Section 614(f) of the House single-payer bill (but not the Senate version) explicitly prohibits the new federal program from “utiliz[ing] any quality metrics or standards for the purposes of establishing provider payment methodologies.” If all doctors and hospitals will get paid the same under single payer, such that the federal government cannot pay good doctors and hospitals more money, how exactly can medical providers compete on the basis of quality (or anything else, for that matter)?
Finally, Warren focuses heavily on aggregate effects of provider pay, while ignoring important underlying trends. In fairness, doctors and hospitals who see many Medicaid patients could see their overall payments go up under single payer, because most state Medicaid programs pay providers less than the current Medicare program.
However, providers with a large share of patients with private insurance (which pays far more than the current Medicare program) will likely receive a significant decline in their reimbursements. Calling these providers “inefficient,” as Warren does in her plan, does not take away from the fact that they would have to engage in pay cuts or significant layoffs—an April Journal of the American Medical Association study suggested up to 1.5 million job losses from hospitals alone—to become “efficient” (assuming that is even possible).
Gimmick Factor: 9. This argument revolves around an argument easily rebutted by logic: Doctors and hospitals will not accept less pay to engage in more work.
Savings Proposal 4: Lower Hospital Payments (Part II)
How Much: A total of $2.3 trillion in savings, by paying hospital-owned physician offices at the physician office rate ($500 billion in savings), reforming post-acute care payments ($500 billion), and instituting bundled payments that combine inpatient care with 90 days of post-acute care ($1.2 trillion in savings). Presumably, the difference between the $2.3 trillion total and the $2.2 trillion sum of its component parts reflects rounding, but the paper does not say so outright.
What’s the Catch? For starters, one can raise legitimate questions about the accuracy of Warren’s numbers. More than half of the savings, derived from the bundling of post-acute care, come from a Congressional Budget Office estimate from November 2013—i.e., six years ago. To the extent that the budget scores have changed, doctors and hospitals have already engaged in the kinds of reforms the paper calls for, or the Urban Institute’s modeling (upon which the Warren campaign based their estimates) has already captured these changes, the plan relies on unrealistic and outdated assumptions to generate its supposed savings.
Moreover, the document admits that “we further adjusted the bundled payment extrapolation to reflect the desired policy outcome of reducing this spending”—that is, “an additional reduction [in hospital payment rates] to achieve this spending aim.” Her campaign provided no details as to the specifics of that “further adjust[ment],” or the policy justification for doing so.
More broadly, depending upon whether one uses the current national health expenditure projections, the Urban Institute’s estimates of health spending under single payer, or a mix of the two, this proposal would reduce health spending for hospitals and post-acute care providers by anywhere from 5-10 percent, on top of the payment reductions located elsewhere in the plan. It seems highly unlikely that such reductions would prove economically, let alone politically, sustainable.
Gimmick Factor: 6. In theory, the health-care system could benefit from lower spending associated with these reforms. But in some cases, the changes may have already taken place—and in others, the cuts may dig too deep when combined with other payment reductions in the plan.
Savings Proposal 5: Lower Spending Growth Rates
How Much: A total of $1.1 trillion in savings compared to the Urban Institute estimates, by presuming that the growth in health-care spending will decline, such that it will equal the growth in overall gross domestic product. If costs continue to grow above GDP, the paper cites “several policy levers…to keep [costs] near GDP growth, including global budgets, population-based budgets, and automatic rate reductions.”
What’s the Catch? Most of the above options would presumably result in one-time savings to the health-care system. Payments would drop—and in some cases, drop quite dramatically—but after that drop, would continue to grow. But the paper states Warren’s plan “will certainly work to lower cost growth over time,” and assumes additional savings in future years on that basis.
However, the few specific ideas mentioned to keep the growth of health care costs at or below GDP growth—such as global budgets and automatic rate reductions—have serious drawbacks. Consider what the Congressional Budget Office said in a May report about under-funding in Britain’s single-payer health system:
Since 2010, the global budget in England has grown by about 1 percent annually in real (inflation-adjusted) terms, compared with an average real growth of about 4 percent previously. The relatively slow growth in the global budget since 2010 has created severe financial strains on the health care system. Provider payment rates have been reduced, many providers have incurred financial deficits, and wait times for receiving care have increased.
What does that kind of chronic under-funding mean for patients? In Britain in January 2018, it meant 55,000 operations cancelled, waits of up to 12 hours in emergency rooms, and ER doctors apologizing for “Third World conditions” in their wards due to overcrowding. That is how Britain “saved” money on health care.
Gimmick Factor: 9. The assumption of further spending reductions reflects either an over-optimistic assumption, or an implicit admission that Warren will arbitrarily reduce health care spending to meet set targets. Given that Donald Berwick—of the infamous quote that “the decision is not whether or not we will ration care, the decision is whether we will ration with our eyes open”—co-authored Warren’s plan, the latter may in fact be the case.
Savings Proposal 6: Re-Direct State and Local Spending
How Much: $6.1 trillion, obtained by redirecting existing state and local spending on Medicaid ($3.4 trillion), and on premiums and health costs for state and local government employees ($2.7 trillion), to fund single payer.
What’s the Catch? Here, the catch comes less in the form of a budget gimmick than via political and legal obstacles. States fought the “clawback” payments included in the 2003 Medicare Modernization Act, which reflected a shift in funding prescription drug payments from the states to the federal government. They and local governments would likely object to any attempt to force them to fund single payer.
It is unclear what ability (if any) the federal government would have to force states to make such payments in perpetuity. Beginning with a 1997 decision that struck down elements of the Brady Bill, the Supreme Court has begun to reassert the Tenth Amendment’s prohibition on the federal government issuing orders to independently sovereign states. The 2018 ruling that allowed states to legalize sports gambling continued this anti-commandeering trend.
Similarly, the Supreme Court’s 2012 ruling that made Medicaid expansion optional for the states said Obamacare engaged in “economic dragooning” of the states. Requiring states and local governments to contribute more than $6 trillion to the federal government in the course of a decade seems like a clear example of “economic dragooning,” making it constitutionally questionable at best.
Also of note: While this $6.1 trillion in re-directed spending actually represents a funding option—replacing federal spending with state and local dollars—Warren’s plan tried to characterize it as a source of “cost reduction.” More accurately characterizing this spending as a funding source rather than as cost savings would increase the price tag of her plan from $20.5 trillion to $26.6 trillion over a decade.
Gimmick Factor: 7. If the left had any regard for the Constitution, they would question the viability of these types of proposals. Warren seems little concerned with such mere trifles.
Revenue Proposal 1: Employer Contributions
How Much: $8.8 trillion in contributions from employers, designed to replicate the contributions they currently make towards employees’ health insurance costs.
What’s the Catch? First, economists generally believe that firms will pass the costs of this “contribution” to their workers. Moreover, Warren’s plan would make this contribution mandatory, as opposed to current practice, in which firms can choose whether to offer health benefits to their workers.
Second, Sanders argued over the weekend that his proposal for a 7.5 percent payroll tax would be “more progressive” than Warren’s plan. To the extent that one cares about progressivity in the tax code, Sanders has a point, because a percentage-based payroll tax would impose higher costs for employees with higher incomes.
For instance, a firm employing an individual with a salary of $300,000 would pay $22,500 in payroll taxes—more than most firms pay in contributions to their workers’ coverage—while a firm employing an individual with a salary of only $30,000 would pay one-tenth that amount ($2,250) in taxes. Whether Sanders’ payroll tax would generate enough revenue to fund single payer at a rate of “only” 7.5 percent is a separate question; results from past examples, and from other non-partisan estimates, seem far from promising on that front.
More fundamentally, one line in the document speaks to the problems inherent in this proposal: “Additional rules, including anti-evasion rules, would be developed” (emphasis added). Just some of the language in Warren’s paper describing this mandatory contribution speaks to its complexity, which would impose its own costs on businesses:
To calculate the contribution, employers will determine what they spent on premium contributions for employer-sponsored insurance, other health-related expenses for employees, and health plan administration in each of the last three years, and divide that by the number of employees of the company in each of those years to arrive at their average annual health care cost per employee. (Part-time employees would count in proportion to the number of hours they worked.) A similar calculation would apply to pass-through entities, such as law firms or private equity funds, and health-related expenses now paid by them or their owners or partners, even though such individuals technically are not employees. Self-employed individuals would be required to provide Employer Medicare Contributions if they exceed an income threshold.
Under the first year of [single payer], employers would be obligated to take that per-employee cost, adjust it upwards to account for the overall increase in national health care spending, multiply it by their total number of employees, and contribute 98% of that amount as their Employer Medicare Contribution. Over time, an employer’s health care cost-per-employee would gradually be shifted downwards (or upwards) towards the average health care cost-per employee nationally among firms paying the Employer Medicare Contribution.
The plan implicitly acknowledges the possibilities of gaming this proposal—for instance, by having firms drop their coverage to avoid making contributions. Her paper talks of a “Supplemental Employer Medicare Contribution requirement for large firms with extremely high executive compensation and stock buyback rates”—parameters for each not specified—if the structure outlined above fails to generate the needed $8.8 trillion in revenue.
Gimmick Factor: 8. This “contribution” will not only hit the middle class, it will raise costs for businesses in the process. Some firms may succeed in reducing their contributions, but only by engaging in economically inefficient or complicated behavior.
Revenue Proposal 2: Additional Income Taxes
How Much: $1.4 trillion in revenue coming from employees no longer paying premiums for employer-sponsored insurance on a pre-tax basis, along with the abolition of health-related tax incentives (health savings accounts, itemized deduction for medical expenses, etc.)
What’s the Catch? By no longer having to pay premiums on their employer-sponsored coverage, individuals will save money—at least in theory. But because premiums for employer-sponsored coverage are paid on a pre-tax basis, workers would have to start paying income and payroll taxes on these dollars.
Gimmick Factor: 5. This tax will absolutely hit the middle class, Warren’s claims notwithstanding. Whether one considers this additional revenue a broken promise depends on whether one focuses on the $1 individuals will “save” in premiums, or the 30-40 cents of income and payroll taxes most people will have to pay because that $1 in “savings” now counts as added income.
Revenue Proposal 3: Taxes on Banks
How Much: A total of $900 billion in revenue from a 0.1 percent tax on financial transactions ($800 billion) and a “systemic risk fee” for banks with more than $50 billion in assets ($100 billion).
What’s the Catch? Apart from the fact that such taxes raise costs for retirement funds, and thus every American with a 401(k) or IRA, past experience suggests financial transaction taxes do not raise the amount of revenue promised. Italy, France, and Sweden each raised a fraction of the revenue they originally estimated from a financial transactions tax, in part because the number of trades fell as trading moved elsewhere. In fact, Congress repealed an earlier version of a financial transaction tax in 1965 as poor and ineffective tax policy.
Gimmick Factor: 6. At best these taxes will have little revenue impact, as markets and trading desks adjust their business models. At worst, it will raise costs for savers, including those in the middle class struggling to save for retirement.
Revenue Proposal 4: Taxes on Corporations
How Much: A total of $2.9 trillion in revenue from a repeal of accelerated depreciation ($1.25 trillion) and a country-by-country minimum tax on foreign earnings of 35 percent, the American corporate tax rate Warren wants to return to after repealing the 2017 tax reform legislation ($1.65 trillion).
What’s the Catch? First, as the Committee for a Responsible Federal Budget notes, “much of the revenue from [repealing accelerated] depreciation comes from a timing shift that increases tax payments now but reduces them later.” Under Warren’s proposal, companies could still write off their equipment, they just couldn’t do so as quickly as under current law. As with an expansion of Roth IRAs, this proposal would generate up-front revenue, but that revenue would decline over time.
Second, increasing corporate tax rates—which Congress just lowered, with bipartisan support—would again encourage companies to relocate overseas. An appendix to Warren’s paper admits that the long-term revenue impact of this change “depends on how U.S. multinationals would change the location of their profits, the location of their headquarters (i.e., inversions), and the evolution of the tax rates applied by other countries.” Ironically enough, if other countries raise their tax rates, a minimum tax on foreign earnings would yield the United States no revenue.
Gimmick Factor: 7. The depreciation proposal by definition will generate diminishing revenue for the federal government, and both will encourage companies to make inefficient, and therefore growth-sapping, decisions to avoid taxes.
Revenue Proposal 5: Taxes on ‘The 1 Percent’
How Much: A total of $3 trillion in revenue from high earners, including an additional 3 percent wealth tax on those with net worth over $1 billion ($1 trillion) and higher capital gains taxes for “the top 1 percent” ($2 trillion).
What’s the Catch? The first prong of this proposal would increase Warren’s wealth tax from 3 percent to 6 percent. (Her initial 3 percent wealth tax would fund other proposed programs.) This tax would force individuals to forfeit to the federal government 6 percent of their net worth per year, every year.
Lawrence Summers, a former advisor to both Presidents Clinton and Obama, wrote earlier this year that Warren’s initial wealth tax would not generate as much revenue as promised, due to likely attempts at tax avoidance. (Summers also noted that nine of 12 countries in the Organization for Economic Cooperation and Development have repealed their wealth taxes since 1990, finding them too cumbersome to administer.)
For instance, individuals could accelerate donations to charities, to decrease the amount of their wealth subject to the tax. Doubling the proposed wealth tax rate from 3 percent to 6 percent would only encourage this type of behavior, lowering its potential to generate revenue.
The second prong of this proposal would require “the top 1 percent” (not defined more specifically) to pay capital gains taxes every year. If a stock held by such an individual rose from $40 to $45 during a year, for instance, the individual would owe taxes on the $5 worth of appreciation—whether the individual sold the stock or not.
Beyond the fact that individuals might have to sell assets early just to pay the new capital gains tax, Warren’s proposal creates another problem: This “mark-to-market” approach would likely lead to major revenue fluctuations, and potentially revenue losses, for the federal government during recessions. For instance, if the stock held by the individual referenced above dropped in value from $45 to $35 over the course of a year, the individual could write off that $10 loss too. The net result would be dramatic drops in revenue for the federal government that coincide with drops in the stock market.
Gimmick Factor: 8. Taxing “the rich” may represent good politics, but seems unlikely to generate anywhere near the amount of revenue Warren would have you believe. (It also will generate negative economic impacts—which, as noted above, Warren’s advisors did not consider when arriving at their estimates.)
Revenue Proposal 6: Tax Enforcement
How Much: $2.3 trillion in revenue from increased tax compliance, including additional funding for the IRS’s Criminal Investigation Division, and expanded third-party withholding and reporting requirements.
What’s the Catch? The Congressional Budget Office estimated last December that a $20 billion increase in the IRS’s enforcement budget would raise a total of $55 billion in revenue over a decade. The net increase in revenue of $35 billion amounts to 1.52 percent of the $2.3 trillion Warren promises these provisions would collectively raise.
Gimmick Factor: 9. This proposal likely worked backwards from a number—“Let’s assume we can reduce the tax compliance gap [the gap between taxes owed and taxes paid] from 15 percent down to 10 percent”—and then filled in some policies that they claim could reduce the tax gap by one-third. However, analysts at CBO likely will not use the same crude methodology to derive their estimates, nor should they. Moreover, adding the new requirements Warren proposes will raise compliance costs, including for small business owners and self-employed individuals (including this one) firmly ensconced in the middle class.
Revenue Proposal 7: Immigration Changes
How Much: $400 billion in direct revenue from immigration policy changes.
What’s the Catch? First, the fact that for more than a decade, both Republican and Democratic Congresses have failed to enact immigration legislation, meaning this proposal assumes something that likely will not happen.
Second, the Urban Institute report from which Warren derived her own estimates admitted that “we do not attempt to estimate any potential effect of additional residency (legal or otherwise), or medical tourism that could result” from single payer. It seems one-sided for Warren not to consider any potential increase in health-care spending resulting from immigrant populations—because even Hillary Clinton has admitted that “too many…illegal aliens…come in [to the United States] for medical care as it is”—while simultaneously using tax revenue from immigration reform to pay for her plan.
Third—and most importantly—Warren’s plan relies on a 2013 Congressional Budget Office score of an immigration reform plan to derive its supposed $400 billion in revenue. But that CBO score showed that the budgetary savings from enacting immigration reform came off-budget. That means that some or all of the “revenues” from immigration reform—which Warren wants to use to fund single payer—could come from immigrants paying payroll taxes, which they will eventually receive back in the form of Social Security payments.
Just like Democrats used reductions in Medicare spending both to “save Medicare” and “fund [Obamacare],” Warren apparently looks to use the same money from immigration reform twice—first to fund single payer, and then to fund Social Security benefits for new immigrants.
Gimmick Factor: 10. Warren knows she can’t use immigration to pass single payer, and her advisors undoubtedly know that any payroll tax revenue from changes to immigration laws would need to be directed to Social Security benefits. They just found themselves short of revenue, and decided to add changes to immigration laws as a “magic asterisk” to make their numbers work—at least on paper.
Revenue Proposal 8: Elimination of the Overseas Contingency Operations Fund
How Much: $800 billion from eliminating and defunding the Overseas Contingency Operations Fund.
What’s the Catch? Ironically enough, OCO’s prominence—and Warren’s decision to use it as a funding source for single payer—comes in large part from its current use as a budget gimmick. The 2011 Budget Control Act exempted OCO funds from the legislation’s caps on defense spending. To avoid a sequester of defense spending under the BCA, Congress and the administration have used OCO to fund operations previously included in the “base” Pentagon budget, and which have little or no direct connection to overseas operations, or the Global War on Terror.
As it happens, however, the Budget Control Act’s enforcement mechanisms for discretionary spending (including defense spending) are already scheduled to expire at the end of Fiscal Year 2021—September 30, 2021. Warren’s pledge to eliminate an account whose prime purpose (i.e., circumventing defense spending caps and the sequester) will already end eight months after her potential inauguration seems unnecessary at best, and disingenuous at worst.
Gimmick Factor: 8. This particular example of fiscal legerdemain seems particularly meta—engaging in one budget gimmick by repealing another budget gimmick.