Indian Health Service Scandal Shows Problems of Government-Run Care

As if voters didn’t have enough reasons to question government-run health care, the Wall Street Journal provided yet another last week. The paper ran a lengthy expose highlighting numerous cases of doctors previously accused of negligence receiving “second chances” in the government-run Indian Health Service (IHS), resulting in incidents wherein at least 66 patients died in IHS care.

Earlier this year, the Journal ran a separate investigative article explaining how the Indian Health Service repeatedly ignored warnings about a physician accused of sexually abusing patients, moving him from hospital to hospital. Together, these articles describe a broken culture within the Indian Health Service, demonstrating how government-run health systems provide poor-quality care, often harming rather than helping vulnerable patients.

Examples of Negligent Physicians Harming Patients

The Journal examined records from the Treasury’s Judgment Fund, which pays awards in malpractice cases wherein the federal government — in this case, the Indian Health Service — functions as the defendant. The reporters then cross-referenced the physicians involved in those cases with prior malpractice cases and disciplinary actions taken prior to the doctors joining the IHS. The results should shock patients:

  • A doctor “thrust into medical exile” after five medical malpractice settlements in five years, including a rejection by a Nevada licensing board, ended up finding work in the Indian Health Service, where the federal government had to pay an additional five malpractice claims on his behalf. The physician, who had previously left a sponge inside a patient’s breast (among other incidents) before going to work with the Indian Health Service, gashed an IHS patient’s bile duct, causing four liters of digestive fluid to leak into her abdomen and sending her into septic shock.
  • An obstetrician with a history of five malpractice settlements totaling $2.7 million, and sanctions from the California medical board stemming from a patient who bled to death following a caesarean section, found employment in the Indian Health Service. A year after his hire, a baby died in the womb because this doctor failed to treat his mother’s high blood pressure. IHS officials later concluded that the doctor’s history “forshadow[ed] the tragic events that transpired in October 2017.” The physician admitted to the Journal, “I just did not address patients’ primary medical needs in a satisfactory way.” But he still applied for and received a position with the IHS.
  • A surgeon sued for malpractice 11 times over an eight-year period while living in Pennsylvania later got a job with the Indian Health Service in New Mexico. There he “allegedly cut a tube connecting a patient’s liver to his stomach and punctured the man’s intestines during a 2008 gallbladder surgery.” The patient later died.
  • A physician disciplined in both Florida and New York for prescribing pain pills for her boyfriend — up to 1,350 oxycodone pills in a single day — was hired by the Indian Health Service because she had a “clean” medical license in Pennsylvania. While working for the IHS, she sent a patient complaining of dizziness home with a diagnosis of pink-eye. Days later, the patient suffered a stroke that has left him confined to a wheelchair and unable to speak. The federal government settled the subsequent malpractice case for $1 million because “hospital officials said in interviews that the doctor’s background made the case hard to defend.”
  • Another surgeon with nearly a dozen malpractice suits and a suspension for sexually abusing a patient during an exam received a job with the Indian Health Service. During his time as an IHS employee, the federal government paid a judgment exceeding $600,000 “over a colostomy the doctor performed that spilled fecal matter under a patient’s skin” and a $500,000 settlement for a botched hernia repair.
  • An obstetrician with at least seven reports in the National Practitioner Data Bank, including North Carolina sanctions over a potential sexual relationship with a patient, got a job with the Indian Health Service. In 2013, the doctor “struggled to deliver a baby” at an IHS facility. The baby developed an irregular heartbeat and died. The federal government paid a $900,000 malpractice claim because “a medical board reprimand later said [the doctor] should have resorted to a [caesarean] section ‘hours earlier.’”
  • A surgeon who lost his medical license in Illinois for “gross negligence” got another chance at a New Mexico IHS facility. “Two months after he arrived as the [IHS] hospital’s chief of surgery, he allegedly punctured a patient’s intestines during a surgery.” The patient ended up needing a dozen surgeries — which she wisely obtained outside the Indian Health Service — and a four-month hospital stay to recover.

Bureaucratic Nightmares

The Journal article also explained the circumstances by which all these physicians with histories of multiple malpractice claims or disciplinary actions came to work in the Indian Health Service. First, while the agency’s policies require hiring managers to consult the National Practitioner Data Bank for a physician’s history of malpractice claims or sanctions, the IHS does not monitor compliance with that requirement.

In one case, the CEO of a hospital who fired a surgeon for negligence said she “encourag[ed] him to consider another field of medicine than surgery.” However, the CEO didn’t know the surgeon had ended up practicing at an IHS facility until the Journal contacted her — because IHS apparently failed to investigate the surgeon’s history before hiring him.

Second, the federal government covers physicians’ malpractice claims through the Treasury’s Judgment Fund (the way the Journal reporters researched the hysicians’ history). Because IHS doctors don’t need to pay for malpractice insurance themselves — what one survey of IHS physicians considered the top benefit of working at the agency — it has become an effective “dumping ground” for physicians whose history of prior malpractice claims means they cannot obtain insurance on their own. IHS patients and federal taxpayers often end up paying the price, both literally and figuratively.

Poor Reimbursements Equal Poor Care

One former IHS official admitted that hiring managers have to make compromises when hiring physicians: “You get three candidates who come through and they all seem not great. But what you do is choose the lesser of three evils.” Hiring those “lesser evils” led to disastrous and often fatal consequences for dozens upon dozens of Indian Health Service patients.

Sen. Elizabeth Warren, D-Mass., says she wants to extend government-run health care to the rest of the United States. But rather than apologizing to Native Americans for DNA tests, she should instead apologize for the horrid conditions within the Indian Health Service, promise to replace that broken system with something that works, and vow not to wreak on the rest of the American health-care system the kind of havoc Native populations have faced for years.

This post was originally published at The Federalist.

The Costs of “Free” Health Care

Libertarian columnist P.J. O’Rourke once famously claimed that “If you think health care is expensive now, wait until you see what it costs when it’s free.” A left-of-center think-tank recently confirmed O’Rourke’s assertion. In analyzing several health care proposals, the Urban Institute demonstrated how eliminating patient cost-sharing from a single-payer system would raise total health care spending by nearly $1 trillion per year.

Those estimates have particular resonance given the recent release of a health care “plan” (such as it is) by Sen. Elizabeth Warren (D-Mass.). Warren’s policy proposals contain myriad gimmicks and rosy scenarios, all designed to hide the obvious fact that one cannot impose a $30 trillion-plus program on the federal government without asking middle-class families to paya lot—for its cost.

The Urban Institute estimates show that a single-payer plan maintaining some forms of patient cost-sharing (i.e., deductibles, co-payments, etc.) seems far more feasible—or less unfeasible—than the approach of Warren and Sen. Bernie Sanders (I-VT), who promise unlimited “free” health care for everyone. Mind you, I would still oppose such a plan—for its limits on patient choice, economically damaging tax increases, and likelihood of government rationing—but at least it would have the advantage of being mathematically possible. Not so with Sanders’ and Warren’s current approach.

Option 1: An Obamacare-Like Single-Payer Plan

In the October policy paper, several Urban researchers examined the financial effects of various health coverage proposals, including two hypothetical single-payer systems. The first single-payer system would cover all individuals legally present in the United States. Urban modeled this system to cover all benefits required under Obamacare, and fund 80 percent of Americans’ expected health costs per year, equivalent to a Gold plan on the Obamacare exchanges. Americans would still pay the other 20 percent of health spending out-of-pocket.

This proposed “lite” single-payer system would still require massive tax increases—from $1.4-$1.5 trillion per year. But it would actually reduce total health spending by an estimated $209.5 billion compared to the status quo.

This single-payer system generates calculated savings because Urban assumed the plan would pay doctors current rates under the Medicare program, and pay hospitals 115 percent of current Medicare rates. Because Medicare pays medical providers less than private insurers, moving all patients to these lower rates would reduce doctors’ and hospitals’ pay—which could lead to pay and job cuts for health professionals. But in the Urban researchers’ estimates, it would lower health spending overall.

Option 2: ‘Free’ Health Care Costs a Lot of Money

Compare these outcomes to a proposal closely modeled on the single-payer legislation supported by Sanders and Warren. Unlike the first proposal, this “enhanced” single-payer system would cover “all medically necessary care,” with “no premiums or cost-sharing requirements.” It would also enroll all U.S. residents, including an estimated 10.8 million illegally present foreign citizens.

The Urban researchers found that the single-payer plan with no cost-sharing would raise total health spending by $719.7 billion compared to the status quo. Compared to the “single-payer lite” plan, which provides benefits roughly equivalent to Obamacare, eliminating cost-sharing and covering foreign citizens would raise total health spending by $929.2 billion. Moreover, the plan with no cost-sharing requires a tax increase nearly double that of the “single-payer lite” plan—a whopping $2.7-$2.8 trillion per year.

The Urban Institute estimates confirm that making all health care “free,” as Sanders and Warren propose, would cause an enormous increase in the demand for care. This would overwhelm any potential savings from lower payments to doctors and hospitals, meaning the health sector would face a double-whammy, of getting paid less to do more work. These estimates also could underestimate the growth in health spending, because Urban’s researchers did not assume a rise in medical tourism or immigration when calculating the increase in demand for “free” health care.

Socialists’ ‘Solution’: Hold Costs Down by Rationing

Socialist supporters of Sanders’ plan attacked these estimates, claiming that the Urban Institute failed to consider that a single-payer system would ration access to “free” health care. The People’s Policy Project called Urban’s estimates of increased demand “ridiculous,” in part because “there is still a hard limit to just how much health care can be performed because there are only so many doctors and only so many facilities.”

Its position echoes that of the socialist magazine Jacobin, which in response to a single-payer study by the Mercatus Center last year admitted that “aggregate health service utilization is ultimately dependent on the capacity to provide services, meaning utilization could hit a hard limit.”

An increase in health spending of nearly $1 trillion per year, and increased waiting times and rationed access to care: either or both of those scenarios represent the costs of “free” health care, based on the words of leftists themselves. The prospect of either scenario should make Americans reject this socialist approach.

This post was originally published at The Federalist.

UK Debate Shows Single Payer’s Shortcomings

This week’s debate featuring candidates for the highest office in the land showed all the problems with single-payer health care. Except the debate took place in Britain, not the United States.

During Tuesday’s debate between the current British prime minister, Conservative Boris Johnson, and the man who wants to replace him, Labour’s Jeremy Corbyn, both agreed that Britain’s National Health Service (NHS) currently provides poor care to patients. That surprising consensus in an otherwise-contentious debate illustrates why the United States shouldn’t import Britain’s poor quality of care to our shores.

‘Make Sure Nobody Else Goes Through This Pain’

The debate featured a question by a hospital-based physician, who said he “see[s] firsthand the unsustainable pressure on the NHS—elderly patients stuck on trollies in corridors, unacceptably long waiting times for operations.” He asked how the health service can meet future demands, when it arguably doesn’t meet the current patients’ needs.

After calling the NHS a “wonderful and brilliant institution,” Labour’s Corbyn then recounted a heart-rending tale of how it let down one patient just this week:

Yesterday, a woman—friend of mine—died at 6:30 yesterday morning from secondary breast cancer. The day before, she’d gone to hospital, at the recommendation of her GP [general practitioner], in order to get urgent treatment. She waited eight hours. The nurses that were trying to help her were unable to get anyone to see her because they were under such strain and stress. And so she recorded a video saying, ‘Please, in my memory—make sure nobody else goes through this pain.’

Corbyn then concluded by calling for increased spending, claiming that the NHS stands as “one of the most civilized things about this country.” His friend might have objected to that characterization—but thanks to the NHS, she never lived to see Corbyn make his comment.

Waiting Times

Johnson likewise pledged additional funding, but the effects of choices made in the last several years have affected NHS. In a May report, Congressional Budget Office analysts stated that “the relatively slow growth in [payments to hospitals] since 2010 ha[ve] created severe financial strains on the [British] health care system. Provider payment rates have been reduced, many providers have incurred financial deficits, and wait times for receiving care have increased.”

While Corbyn’s comments brought home the personal impact of the NHS’ failures, data compiled by the House of Commons Library (Britain’s version of the Congressional Research Service) demonstrates that stories like the one Corbyn recounted have become far too common.

Charts like those below need very little explanation. A roughly five-fold increase in the number of patients waiting more than four hours in emergency rooms since 2011:

A nearly five-fold increase in the number of patients waiting on trollies in emergency rooms for hours after their doctors decided to admit them as inpatients:

A 40 percent increase in the number of people on the NHS waiting list, such that it now totals 4.56 million people, or nearly 7 percent of the entire British population of approximately 67.5 million:

A majority of NHS trusts breaking the target that a patient should wait “only” 18 weeks (i.e., four and a half months) for treatment led by a consultant (i.e., a medical specialist):

More than three-quarters of NHS trusts breaking the target that patients should receive their first treatment for “urgent” cancer within 62 days (i.e., two months) of their GP referral:

All this poor performance—people waiting and waiting for care—comes as the number of doctors and nurses within the NHS has increased over the past decade (and in the case of physicians, has increased by nearly 20 percent).

Fundamental Dilemma

Johnson and Corbyn can pledge all the additional money for the NHS they want. Their promises won’t solve the health service’s fundamental problem—and may end up bankrupting Britain in the process.

Britain’s pledge of an NHS “free at the point of use” creates the problem. People who believe they can receive “free” care over-consume it, with the types of rationing and wait times seen in the past several years the inevitable consequence.

Voters in the United States who tuned into Wednesday’s Democratic debate to see the candidates talk single payer should have spent their time watching Tuesday night’s prime ministerial debate instead. Few who watched that event would come away thinking that single payer would represent anything less than an unmitigated disaster for the American health care.

This post was originally published at The Federalist.

November Debate Outs Democrats’ Health Care Double Speak

Ten Democratic candidates took the stage in Atlanta for the latest presidential debate on Wednesday evening, and as with the past several debates, health care played an important role. The attack lines echoed debates past: Progressives like Sens. Elizabeth Warren (D-Mass.) and Bernie Sanders (I-Vt.) pledged support for full-fledged socialized medicine, while so-called “moderates” like former Vice President Joe Biden expressed opposition to taking away Americans’ existing health plans, and raising taxes by tens of trillions of dollars to do so.

Several contradictions emerged. First, as in debates past, the controversy seemed focused more on tactics than on strategyhow quickly to take away Americans’ health insurance, rather than whether the United States should ultimately end up with a system of socialized medicine.

Warren’s Unrealistic Promises

Early in the debate, Warren tried to square the circle into which she has put herself, by first releasing a plan for full-on single payer, and then releasing a second “transition” plan last Friday. In the latter plan, Warren pledged she would pass not one but two separate major pieces of health care legislation through Congress—the first within her 100 days, the second within three years.

Warren claimed that she would provide access to “free” health care for 135 million Americans within her first 100 days in office. That number comes from the populations that she pledged in last week’s plan would have immediate access to a Medicare-type single-payer system without premiums or cost sharing: Those with incomes under 200 percent of the federal poverty level (currently $51,500 for a family of four), and all children under age 18.

The idea that Warren can introduce, let alone pass, such massive legislation within 100 days—by April 30, 2021—seems unrealistic at best. By way of comparison, the Senate Health, Education, Labor, and Pensions Committee—the first committee to mark up the legislation that became Obamacare—did not even introduce its version of the bill until June 9, 2009, well after Barack Obama’s first 100 days in office. Barack Obama did not sign Obamacare into law until March 23, 2010, 427 days after his inauguration.

Drafting and passing a bill providing “free” health care to only 135 million people (as opposed to more than 300 million in full-on single payer) would in and of itself represent one of the largest and costliest pieces of legislation—if not the largest and costliest piece of legislation—ever considered by Congress. It would also require massive tax increases, which given the gimmicks in Warren’s plan would likely fall on the middle class.

The idea that Congress could pass such large legislation in only 100 days seems unrealistic at best, and an affront to democracy at worst. Underpinning this timetable lies the idea that “we have to pass the bill so that you can find out what’s in it,” because Democrats fear the ramifications of allowing the American people to understand the effects of their agenda before enacting it. In reality, however, trying to pass legislation that fast would quickly become a legislative morass for Warren, much like the political morass (of her own making) that she currently faces on health care.

Does Biden Believe in Choice?

Biden also spoke out of both sides of his mouth on health care. He claimed that 160 million Americans with employer-sponsored coverage like their current insurance, and that he trusts the American people to decide whether or not to join a government-run plan.

However, Biden also claimed that his plan would bring down costs and premiums for the American people. Those reductions can only materialize if people end up enrolling in the government-run health plan, because it would use raw government power to pay doctors and hospitals less.

On the one hand, Biden claims he believes in choice. But on the other hand, his rhetoric belies his desire for a given outcome, one in which people “choose” the government-run plan. As with Pete Buttigieg’s claim that a government-run plan would provide a “glide path” to single payer, both Biden’s rhetoric and the details of his plan show that he wants to sabotage private insurance to drive people into the government-run plan.

Forcing everyone into socialized medicine, and dissembling to voters while doing so: That’s the agenda the American people saw on display in Atlanta Wednesday evening.

This post was originally published at The Federalist.

How Elizabeth Warren “Swift Boated” Herself on Health Care

Every four years, political analysts and commentators compare current presidential candidates to events from campaigns past. She may not want to admit it, but Sen. Elizabeth Warren’s actions on health care the past several weeks, culminating in the release of her second health plan on Friday, echo the 2004 presidential campaign of her Massachusetts colleague, former Sen. John Kerry.

During his campaign for the Democratic nomination, Kerry played up his military service at every opportunity. Howard Dean’s strident opposition to the Iraq War, coupled with his infamous on-camera implosion after the Iowa caucuses, gave Kerry an opening that he parlayed into the Democratic nomination. At the party’s convention in Boston, Kerry famously started his acceptance speech with a military salute: “I’m John Kerry, and I’m reporting for duty.”

The Swift Boat Veterans for Truth ads that ran after the Democratic convention attempted to turn Kerry’s biggest strength—his military service—into a weakness. The ads sparked controversy, and no small amount of political attention, by raising questions about Kerry’s service in Vietnam, and his activities protesting the Vietnam War following his return.

Likewise, the past several weeks have seen Warren turn her biggest strength—her wonky, “I’ve got a plan for that” persona—into a weakness. On November 1, she released her first health-care plan, replete with multiple documents highlighting supposed savings under a single-payer health-care system, and her plan for raising revenue to pay for such a system without raising taxes on the middle class.

Warren’s first plan drew mockery from her fellow Democratic candidates and conservative commentators alike for its unrealistic gimmicks and assumptions. Most notably, Warren’s plan failed to concede what one of her own advisors implicitly admitted: That an $8.8 trillion “employer contribution” would ultimately come out of the pockets of the middle class. Meanwhile, her opponents continued to hammer Warren for wanting to strip away the existing insurance of millions of Americans, including union workers who negotiated their health coverage at the bargaining table.

Her initial plan failed so badly that exactly two weeks later, Warren felt the need to reboot. She released another health plan, this one highlighting a supposed “transition period,” to get ahead of criticism from her fellow Democrats in the upcoming presidential debate.

This plan pledged that, within her first 100 days in office, Warren would work to enact “a true Medicare for All option”—one that people could select if they chose, but would not require individuals to give up their existing coverage. Only later, “no later than my third year in office,” would Warren “fight to pass legislation that would complete the transition” to a full single-payer system.

The second plan seems like a deliberate dodge, an attempt for Warren to have her cake and eat it too. The single-payer bill introduced by Sen. Bernie Sanders (I-VT)—which Warren has co-sponsored—contains a four-year transition plan in Title X of the underlying legislation. The single-payer bill introduced in the House by Rep. Pramila Jayapal (D-WA) also includes a transition, which would take place over a two-year period. Warren’s claim that Congress should pass not one but two major bills to enact her health-care agenda sounds like an excuse for her to walk away from her commitment to single payer.

On that count, who can blame her? Evidence from the midterm elections shows that support for full-on socialized medicine cost the average Democrat in a competitive district nearly 5 percentage points of support. No wonder that even Barack Obama conceded on Friday that “the average American doesn’t think we have to completely tear down the system” and cautioned Democrats against proposing “crazy stuff,” in a not-so-subtle warning about proposals by Warren and Sanders.

But Warren now remains firmly mired in a mess of her own making. Her “I’ve got a plan for that” mantra meant she had to release a detailed health care proposal at a time political expediency might have suggested vagueness. Her Democratic rivals, to say nothing of President Trump’s re-election, can now pick apart those details over many months.

And to think those details won’t matter to the American people, or lead to additional controversy, belies past experience. When House Speaker Nancy Pelosi admitted in 2010 that “We have to pass [Obamacare] so that you can find out what’s in it,” she conceded that the legislative details matter to millions of Americans—and that such public scrutiny put Democrats in political peril.

Hours before she released her first health-care platform, an article on the issue correctly claimed that “Warren did not have a plan for this.” Her initial lack of a plan, followed by her willingness to spell out in minute relief the details of her socialized medicine plan, could prove her undoing.

This post was originally published at The Federalist.

Warren Advisor Admits Her Health Plan Raises Middle Class Taxes

That didn’t last long. Five days after Sen. Elizabeth Warren released a health plan (chock full of gimmicks) that she claimed would not raise taxes on the middle class, one of the authors of that plan contradicted her claims.

In an interview with Axios published on Wednesday, but which took place before the plan’s release, Warren advisor and former Centers for Medicare and Medicaid Services Administrator Donald Berwick said the following:

Q: Many people may not know their employers cover 70% or more of their entire premium — money that otherwise would go to their pay. Is this the main problem when talking about reforms?

DB: The basics are not that complicated. Every single dollar — every nickel spent on health care in this country — is coming from workers. There’s no other source. [Emphasis mine.]

Compare that phraseology to what Joe Biden’s campaign spokesperson said on Friday about Warren’s plan and its effects:

For months, Elizabeth Warren has refused to say if her health care plan would raise taxes on the middle class, and now we know why: Because it does….Senator Warren would place a new tax of nearly $9 trillion that will fall on American workers. [Emphasis mine.]

In response to the Biden campaign’s criticism, Warren said last Friday that her health plan’s projections “were authenticated by President Obama’s head of Medicare”—meaning Berwick. Unfortunately for Warren, Berwick, by virtue of his comments in his interview with Axios, also “authenticated” Biden’s attack that her required employer contribution will hit workers, and thus middle-class families.

Warren also tried to defend her plan on Friday by claiming that “the employer contribution is already part of” Obamacare. Obamacare does include an employer contribution requirement, but that requirement:

  • Is capped at no more than $3,000 per worker, far less than the average employer contribution for workers’ health coverage—$14,561 for family coverage as of 2019— which will form the initial basis of Warren’s required employer contribution;
  • Does not apply to employers at all if the firm offers “affordable” coverage—an option not available under Warren’s plan, which would make private insurance coverage “unlawful;” and
  • Will raise an estimated $74 billion in the coming decade, according to the Congressional Budget Office—less than 1 percent of the $8.8 trillion Warren claims her required employer contribution would raise.

While Obamacare and Warrencare both have employer contributions, the similarities pretty much end there. Calling the two equal would equate a log cabin to Buckingham Palace. Sure, they’re both houses, but differ greatly in size. Warren’s “contribution”—which Berwick, her advisor, admits will fall on middle-class workers—stands orders of magnitude greater than anything in Obamacare.

Public Accountability?

In the same Axios interview, Berwick highlighted what he termed a tradeoff “between public accountability and private accountability.” He continued: “By not having a publicly accountable system, we are paying an enormous price in lack of transparency.”

His comments echo prior justification of his infamous “rationing with our eyes open” quote in a 2009 interview. As he explained to The New York Times as he departed CMS in late 2011, “Someone, like your health insurance company, is going to limit what you can get….The government, unlike many private health insurance plans, is working in the daylight. That’s a strength.”

Except that Berwick, as CMS administrator, went to absurd lengths to hide from public scrutiny after his series of remarks. He would gladly meet with health-care lobbyists behind closed doors, but refused to answer questions from reporters, going so far as to duck behind curtains and request security escorts to avoid doing so.

Warren apparently has taken a lesson in opacity from Berwick’s time as CMS administrator. At first, she avoided releasing a specific health care proposal at all, only to follow up by issuing a “plan” containing so many absurd assumptions as to render it irrelevant as a serious blueprint for legislating.

Unfortunately for her, however, Berwick committed the unforgivable sin of speaking an inconvenient truth about the effects of her proposal. Eight years after leaving office as CMS administrator, Berwick, however belated and however unwittingly, delivered some much-needed public accountability for Warren’s health plan.

This post was originally published at The Federalist.

Analyzing the Gimmicks in Warren’s Health Care Plan

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.

Warren Asks What the Country Can Do for You

Elizabeth Warren’s release Friday of a more specific health-care platform only raised more questions about Medicare for All and its effects on the middle class. Conservatives as well as Ms. Warren’s Democratic opponents questioned the assumptions behind her claim that she can enact a single-payer plan without raising taxes on the middle class. Yet the harshest critic may be Ms. Warren herself. “Ask not what your country can do for you—ask what you can do for your country,” John F. Kennedy, who once held Ms. Warren’s Senate seat, urged. She refuses to ask the middle class to pay a dime for her costly proposal.

Take Ms. Warren’s assumptions at face value, even if doing so requires a knowing suspension of disbelief. Assume she can reduce the 10-year cost of a single-payer system from the $34 trillion in new federal spending estimated by the liberal Urban Institute to a mere $20.5 trillion. Assume her program would reduce administrative costs without encouraging fraud. Assume also that her proposed wealth tax won’t generate massive tax evasion—she claims a Warren administration would generate $2.3 trillion in new revenue by cracking down on tax avoidance—and that not a penny of her $9 trillion in assessments on employers will end up being paid by workers.

Ms. Warren envisions a $20 trillion expansion of government—the largest in American history—paid for by a fraction of the population. She foresees unlimited “free” health care for millions of families, without so much as a $100 copayment, premium, assessment, tax or other fee.

Sure, the earned entitlement always had an element of fiction. Social Security and Medicare pay benefits based on current cash flows, with their respective trust funds containing little more than promises to pay future benefits. Urban Institute estimates show that even wealthy seniors will receive more in Social Security and Medicare benefits than they paid in taxes. But Ms. Warren’s plan would dispense with the pretense of social insurance, instead creating a crass form of political plunder that uses federal largess to buy votes.

In turning government programs into a version of “Oprah’s Favorite Things”—everyone gets a free car, paid for by somebody else—Ms. Warren follows the example of President Obama. He talked of social solidarity, saying “we’re all in this together,” but shied away from asking anyone other than “the rich” to pay for his new government programs. In 2008 candidate Obama made a “firm pledge” not to raise taxes on families making less than $250,000 a year, “not your income tax, not your payroll tax, not your capital-gains taxes, not any of your taxes.”

The “firm pledge” lasted two weeks. In February 2009 Mr. Obama raised tobacco taxes to fund an expansion of children’s health insurance. Then, after ObamaCare took effect in 2013, the law led at least 4.7 million Americans to receive insurance-cancellation notices. In the years since, the health-insurance market has shrunk by four million people, because those who don’t qualify for subsidies can’t afford coverage—what Bill Clinton called “the craziest thing in the world.” Working families ended up bearing the burden of Mr. Obama’s new programs.

Therein lies the true lesson for the American people. Elizabeth Warren may not ask the middle class to fund Medicare for All—at least not until she’s safely in office—but one can rest assured that, should she succeed in enacting her scheme, all American families will pay.

This post was originally published at The Wall Street Journal.