Democratic presidential candidates trying to appeal to progressive voters with a call for "Medicare for All" are wrestling with the thorny question of how to pay for such a dramatic overhaul of the U.S. health care system.
Bernie Sanders, the chief proponent of Medicare for All, says such a remodel could cost up to $40 trillion over a decade. He's been the most direct in talking about how he'd cover that eye-popping amount, including considering a tax hike on the middle class in exchange for healthcare without co-payments or deductibles — which, he contends, would ultimately cost Americans less than the current healthcare system.
His rivals who also support Medicare for All, however, have offered relatively few firm details so far about how they'd pay for a new government-run, single-payer system beyond raising taxes on top earners. As the health care debate dominates the early days of the Democratic primary, some experts say candidates won't be able to duck the question for long.
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"It's not just the rich" who would be hit with new cost burdens to help make single-payer health insurance a reality, said John Holahan, a health policy fellow at the nonpartisan Urban Institute thinktank. Democratic candidates campaigning on Medicare for All should offer more specificity about how they would finance it, Holahan added.
Sanders himself has not thrown his weight behind a single strategy to pay for his plan, floating a list of options that include a 7.5% payroll tax on employers and higher taxes on the wealthy. But his list amounts to a more public explanation of how he would pay for Medicare for All than what other Democratic presidential candidates who also back his single-payer legislation have offered.
Kamala Harris, who has repeatedly tried to clarify her position on Medicare for All, vowed this week she wouldn't raise middle-class taxes to pay for a shift to single-payer coverage. The California senator told CNN that "part of it is going to have to be about Wall Street paying more."
Her contention prompted criticism that she wasn't being realistic about what it would take to pay for Medicare for All. Colorado Sen. Michael Bennet, a rival Democratic presidential candidate, said Harris' claim that Medicare for All would not involve higher taxes on the middle class was "impossible," though he stopped short of calling her dishonest and said only that candidates "need to be clear" about their policies.
A Harris aide later said she had suggested a tax on Wall Street transactions as only one potential way to finance Medicare for All, and that other options were available. The aide insisted on anonymity in order to speak candidly about the issue.
Another Medicare for All supporter, New York Sen. Kirsten Gillibrand, would ask individuals to pay between 4% and 5% of their income toward the new system and ask their employers to match that level of spending. Gillibrand's proposal, shared by an aide who requested anonymity to discuss the campaign's thinking, could supplement the revenue generated by that change with options that hit wealthy individuals and businesses, including a new Wall Street tax.
Gillibrand is a cosponsor of Sanders' legislation adding a small tax to financial transactions, while Harris is not.
New Jersey Sen. Cory Booker, who also has signed onto Medicare for All legislation but said on the campaign trail that he would pursue incremental steps as well, could seek to raise revenue for the proposal by raising some individual tax rates, changing capital gains taxes or expanding the estate tax, according to an aide who spoke candidly about the issue on condition of anonymity.
The campaign of Massachusetts Sen. Elizabeth Warren, who used last month's debate to affirm her support for Sanders' single-payer health care plan, did not respond to a request for more details on potential financing options for Medicare for All.
Meanwhile, Sanders argued during a high-profile Medicare for All speech this week that high private health insurance premiums, deductibles and copayments, all of which would be eliminated by his proposal, amount to "nothing less than taxes on the middle class."
Medicare for All opponents are also under pressure to explain how they'd pay for changes to the health insurance market. Former Vice President Joe Biden is advocating for a so-called "public option" that would allow people to decide between a government-financed plan or a private one. He would pay for his $750 billion proposal by repealing tax cuts for the wealthy that President Donald Trump and the GOP cut in 2017, and by raising capital gains taxes on the wealthy.
Associated Press writers Juana Summers and Alexandra Jaffe contributed to this report.