4 Big Questions About Elizabeth Warren’s Medicare-for-All Plan

Plus, Trump won't rule out another shutdown By Yuval Rosenberg and Michael Rainey Elizabeth Warren’s new [Medicare-for-All plan]( has won the candidate some praise for providing more detail than Bernie Sanders or other Democratic presidential rivals have. But it has also raised plenty of questions, including: The Math Analysts have questioned seemingly every aspect of Warren’s plan, from its assumptions about how much waste can be wrung out of the system to its projection that the government could raise $2.3 trillion in additional revenue just by ramping up Internal Revenue Service enforcement. “The key question in this debate is, how quickly can the United States tamp down its sky-high health care prices?” write Margot Sanger-Katz and Sarah Kliff in an excellent [breakdown]( of the costs and revenues in Warren’s proposal. At the heart of the issue: Warren’s plan used a recent study by the Urban Institute as it baseline for estimating the cost of transitioning to Medicare for All. That study projected the additional 10-year cost to the federal government of a comprehensive single-payer system at $34 trillion. Warren’s plan adjusted that baseline down to $20.5 trillion by making aggressive assumptions — critics call them highly questionable — about how much can be squeezed out of the system by slashing administrative costs, provider payments and drug prices. “The bottom line is that across all sectors of the medical industry, the Warren campaign assumes that her single-payer plan will squeeze much greater savings relative to the current system than the Urban Institute believes is possible—or, in some cases, even desirable,” Ronald Brownstein says at [The Atlantic](. Some analysts contend that, if those assumptions don’t pan out, Warren would eventually need to raise taxes on the middle class — though those hikes might still be smaller than the savings families would see. Others see more fundamental flaws that can’t be overcome. “The good news is, the math adds up, as long as you buy her assumptions. The bad news is that Warren’s assumptions are crazier than keeping a pet rhinoceros, after which, who cares that her calculator works?” libertarian Washington Post columnist Megan McArdle [wrote](. And the Washington Examiner’s Philip Klein, a conservative, said Warren’s plan is so laughable that she “may as well have said Mexico is going to pay for it.” The Feasibility The degree to which Warren’s numbers work or not might not matter all that much when it comes to public opinion and the presidential campaign. (“When the numbers are this big, they’re just pretend,” Saturday Night Live’s Kate McKinnon, playing Warren, said in a [sketch]( on the show this weekend. “Here’s the math. Do you understand this? I do. I could explain it to you, but you would die.") But the numbers have amplified questions about whether the transformation that Warren envisions is realistic. Warren’s plan repeatedly calls Medicare for All a “long-term goal.” Implicit in that language is an acknowledgment that it won’t be enacted anytime soon, even if Warren wins the White House and Democrats keep the House and somehow manage to take control of the Senate. Adding to the challenge, Warren’s financing plan also calls for cuts in defense spending and comprehensive immigration reform to raise tax revenue from newly legal immigrants, both of which would face long odds of getting through Congress. And Axios’s Caitlin Owens [notes]( that, “We've never tried any cost containment measures that are remotely close to being as aggressive as Warren's, and there could be consequences if payment rates are slashed so low.” Patient care could be affected, for example. Industry opposition to Medicare for All will only be heightened by Warren’s proposed payment cuts. “Setting lower prices is going to bring out strong opposition,” Elisabeth Rosenthal, the editor in chief of Kaiser Health News, writes in a New York Times op-ed. “Remember, patient (or taxpayer) savings mean loss of income for one of America’s most profitable industries, whose lobbyists spent more than [half a billion dollars last year]( and which is flush with dark money [to distribute in Congress.]( The Transition Even is Warren is just laying the groundwork for change over the long-term, the question, then, is what happens in the near term. “[V]oters want to know how we get from here to anywhere else. In polls, their top health care issue is [affordability]( — emphasis on now,” says KHN’s Rosenthal. “They need concrete proposals as well as long-term vision.” Some have suggested Warren could shift to supporting a public option as a bridge to her single-payer system, though that might require some Simone Biles-level acrobatics and would inevitably erode some of her support from the left wing of the party. In short, Warren’s detailed Medicare for All plan, even if it’s just a long-term goal, still leaves plenty of near-term questions and vulnerabilities. “Warren has addressed one of the two big political problems with her plan — namely, how she’ll pay for it,” writes New York Times columnist David Leonhardt. “The other problem — people’s anxiety about being forced into a new insurance plan — is still [the larger one]( in my view, and she needs to come up with a reassuring transition plan soon.” The Politics By releasing such a detailed plan, Warren has provided more ammunition to her rivals and raised concerns among centrists that she might cause [down-ballot damage]( to Democrats running in swing districts. And the political attacks have come quickly, from both the left and right. Joe Biden’s campaign, for example, criticized the new taxes in Warren’s plan, arguing that they would hurt the middle class even if they don’t hit them directly. And over the weekend, Bernie Sanders called his plan for funding Medicare for All [far more progressive]( than Warren’s, charging that the $8.8 trillion head tax she would impose on employers would hurt wages and benefits for lower- and middle-income employees. Warren “has ignited fears among many in the Democratic operative class that she has needlessly put herself to the left of the general electorate and created a big vulnerability that could be exploited by Trump,” [writes]( Politico’s John F. Harris. Warren has pushed back on such concerns. “If anyone wants to defend keeping those high profits for insurance companies and those high profits for drug companies and not making the top 1% pay a fair share in taxes and not making corporations pay a fair share in taxes, then I think they're running in the wrong presidential primary,” she said Friday. Trump Won’t Rule Out Another Shutdown Some of President Trump’s critics are worried that he might allow the government to shut down when funding runs out on November 21, in an effort to deflect attention from the ongoing impeachment effort in the House. Asked about the possibility Sunday, Trump denied it. But he then added, "It depends on — it depends on what the negotiation — I wouldn't commit to anything. It depends on what the negotiation is." There’s little appetite among lawmakers to go through another shutdown, and Congress is expected to keep the doors open with a continuing resolution that extends federal funding over a period of weeks or months. However, Politico’s Jake Sherman and Anna Palmer [said]( Monday that with Democrats unwilling to yield in their impeachment investigation, Trump could reach for whatever weapons are available to him, and “if the president is toying with a shutdown in his mind, this month might not be on autopilot as some may think.” A simple process: It doesn’t take much effort to prevent a government shutdown, [says]( Jonathan Bernstein at Bloomberg View. “It’s incredibly easy to keep the government’s doors open; all it takes is a one-page bill changing the expiration date, which could get through Congress in an afternoon.” That assumes, however, that everyone involved wants to avoid a shutdown in the first place. Trump plus impeachment creates a powerful wild card: The president’s refusal to close the door on a government shutdown could just be a negotiating tactic, Bernstein says, though that’s far from certain. “Unfortunately, Trump has a tendency to make the same mistakes multiple times, and congressional Republicans have demonstrated they’re sometimes willing to go along,” Bernstein writes. “The main point is that a shutdown will happen if and only if one side really wants it to. And while all the incentives seem to be lined up against the idea, they were lined up against the first shutdown too.” Court Blocks Trump’s Health-Care Rule for Immigrants A federal judge has temporarily blocked a new rule from the Trump administration that requires immigrants to prove that they have health insurance or can afford to pay for medical care. The rule, announced in a [presidential proclamation]( on October 4, was set to take effect on Sunday. In a Saturday court session in Portland, Oregon, U.S. District Judge Michael Simon issued a 28-day restraining order to prevent the rule from taking effect. A lawsuit opposing the new standard claims that it would unfairly block hundreds of thousands of legal immigrants, and Judge Simon appeared to agree. "Facing a likely risk of being separated from their family members and a delay in obtaining a visa to which family members would otherwise be entitled is irreparable harm," he wrote. Simon also questioned the use of health insurance status as the sole determinant of an immigrant’s admissibility. The Trump administration maintains that immigrants are more likely to be uninsured and are a financial drain on U.S. taxpayers and the health care system. Immigrant advocates charge that the administration is attempting to ban poor immigrants, and health care experts have questioned the claim that immigrants are a serious drain on resources. According to one study [cited]( by Reuters, immigrants who lacked insurance accounted for less than 0.1% of overall medical spending in the U.S. in 2017. What’s next: The lawsuit will continue, and the judge is expected to rule on the merits of the case within the next 28 days. Hospitals Push Back on Price Transparency The Trump administration is delaying a rule that would make hospital prices more transparent. In July, the Centers for Medicare & Medicaid Services proposed requiring hospitals to reveal the secret rates they negotiated with insurers, but a final rule on the requirement has been postponed, according to regulations released Friday. Hospitals and insurers reportedly pushed hard against the proposal during the comment period, and their effort appears to have paid off. “The delay of the transparency rule is a win for payers and providers, who were for the most part adamantly opposed to revealing negotiated rates,” [says]( Samantha Liss of Healthcare Dive. “It would have been a landmark shift for the healthcare system.” More generally, the move suggests that industry players are succeeding in their efforts to resist increased regulation. “The health care industry is winning almost every major policy battle in the Trump administration,” [says]( Axios’s Bob Herman. This [absolutely miserable]( season for the New York Jets was made slightly more tolerable by knowing the Patriots won't go undefeated. Send your tips and feedback to yrosenberg@thefiscaltimes.com. Follow us on Twitter: [@yuvalrosenberg]( [@mdrainey]( and [@TheFiscalTimes](. 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