Unanswered Questions on Single Payer

This month’s Democratic presidential debate will likely see a continued focus on the single-payer health care proposal endorsed by Sens. Bernie Sanders of Vermont and Elizabeth Warren of Massachusetts. But for all the general discussion — and pointed controversy — over single payer at prior debates, many unanswered questions remain. The moderators should ask Sanders and Warren about the specific details of their legislation, such as:

►Section 901(A) of the bill states that “no benefits shall be available under Title XVIII of the Social Security Act” — i.e., Medicare. And an analyst with the liberal Urban Institute has said that “you can call (the bill) many things — from ambitious to unrealistic. But please don’t call it Medicare.” Why do you insist on calling your proposal “Medicare for All” when it would bear little resemblance to the Medicare program and, in fact, would abolish it outright?

►You have claimed that single payer will make health care a human right. But the bill itself does not guarantee access to a doctor — it only guarantees that patients will have their care paid for if they can find a doctor or hospital willing to treat them. In fact, in 2005, the Canadian Supreme Court ruled that “access to a waiting list is not access to health care,” because patients in that country’s single-payer system could not access care in a timely fashion. Why are you promising the American people access to care when your bill falls short of that promise?

►The Urban Institute estimated that a similar single-payer plan would raise national health care spending by $719.7 billion a year, because abolishing cost-sharing (e.g., deductibles, copayments, etc.) will increase demand for care. But the People’s Policy Project called Urban’s estimates “ridiculous,” because “there is still a hard limit to just how much health care can be performed because there are only so many doctors.” Which position do you agree with — the Urban Institute’s belief that individuals consuming more “free” health care will cause spending to rise, or the position that spending will not increase because at least some people who demand care will not be able to obtain it?

►Countries like Canada and Great Britain, both of which have single-payer health care systems, permit individuals to purchase private insurance if they wish — and many Canadians and Brits choose to do so. Why would you go beyond Canada, Britain and other countries to make private health insurance “unlawful” — and do you believe taking away individuals’ private insurance can pass constitutional muster with the Supreme Court?

►Four years ago, your Senate colleague Robert Menendez, D-N.J., was indicted for accepting nearly $1 million in gifts and favors from a Florida ophthalmologist. Menendez had tried to help that ophthalmologist — who was eventually convicted on 67 counts of defrauding Medicare — in a billing dispute with federal officials. Given this ethically questionable conduct by one of your own colleagues regarding the Medicare program, why does your legislation include no new provisions fighting fraud or corruption, even as it vastly expands the federal government’s power and scope?

►You have criticized President Donald Trump for his supposed attempts to “sabotage” the exchanges created under President Barack Obama’s health care law. How, then, would you stop a future Republican president from sabotaging a single-payer system when your legislation would vest more authority in the federal government than President Trump has?

Once Warren and Sanders finish answering these questions, the American people will likely recognize that, the senators’ claims to the contrary notwithstanding, single payer doesn’t represent a good answer for our health care system at all.

This post was originally published at USA Today.

How Socialized Medicine Will Lead to Waits for Care

Recently, a liberal think-tank, the Center for American Progress (CAP), issued a policy paper that promised “the truth” on waiting times in government-run health systems. If you want the truth about the issue, however, you’ll have to wait a long time for it if you choose to rely on CAP’s disingenuous analysis.

The CAP report cherry-picks facts to try to make an argument that a single-payer health-care system won’t result in rationing of health care. Unfortunately, however, even supporters of single payer have admitted that government-run care will increase waiting times for care.

Misleading Analysis

CAP’s paper starts out by criticizing President Trump and other conservative groups, who have asserted that a single-payer system would lead to “massive wait times for treatments and destroy access to quality care,” as Trump stated in his recent executive order on Medicare. CAP calls these assertions “false,” and then claims:

Patients in peer nations generally have similar or shorter wait times than patients in the United States for a variety of services, refuting the argument that universal coverage would necessarily result in longer wait times in the future. [Emphasis added.]

The above sentence, like the rest of the paper, uses clever semantic wordplay to obscure the issue. CAP claims that universal coverage wouldn’t necessarily result in longer wait times, but Trump and the right-leaning groups have criticized one specific form of universal coverage—single payer, in which the government serves as the sole funder of health care. (CAP repeats those misleading tactics by referencing the impact of prior coverage expansions in the United States, many of which used private insurers and none of which directly equate to a universal, government-funded health system.)

Of the paper’s four “peer nations” with universal coverage systems—Australia, France, Germany, and Sweden—only Australia and Sweden have government-run insurance plans. By contrast, France and Germany rely on private insurers to implement their universal coverage systems.

While it includes other systems without single-payer coverage in its analysis, CAP specifically excludes Britain’s National Health Service, known for its waiting times and rationed access to care. CAP claimed to omit the NHS in its analysis because “no candidate currently running for president is proposing nationalizing health care providers” a la the British model—a true enough statement, but a self-serving one.

If CAP included non-government-funded systems in its analysis, it certainly should have included the government-funded NHS. That it did not suggests the analysts wanted to “rig” the paper’s outcomes by relying solely on favorable examples.

Biggest Waiting Times to the North

The CAP paper’s most deliberate omission comes in the form of our neighbor to the north: Canada. The paper examined four metrics of access to care, based on data from an analysis by the (liberal) Commonwealth Fund of 11 countries’ health systems. Given the shabby results Canada’s health system showed on health care access, it seems little wonder that the leftists at CAP failed to disclose these poor outcomes in their paper:

  • Patients who reported they saw a doctor or nurse on the same or next day the last time they needed care: Canada ranked in a tie for last, with 43% agreeing. (The United States had 51% who agreed.)
  • Doctors who reported that patients often experience difficulty getting specialized tests like CT or MRI scans: Canada ranked third from last, with 40% agreeing. (The United States had 29% who agreed.)
  • Patients who reported they waited two months or longer for a specialist appointment: Canada ranked last, with 30% agreeing. (The United States had only 6% who agreed.)
  • Patients who reported they waited four months or longer for elective surgery: Canada ranked last, with 18% agreeing. (The United States had only 4% who agreed.)

As I discuss in my book, Canada’s health system suffers from myriad access problems, based on other metrics from Commonwealth Fund studies that CAP chose not to mention in their paper:

  • The second-lowest percentage of patients (34%) who said it was easy to receive after-hours care without going to the emergency room;
  • The lowest percentage of patients (59%) who said they often or always receive an answer the same day when calling the doctor’s office about a medical issue;
  • The highest percentage of patients (41%) using the emergency room; and
  • The highest percentage of patients (29%) waiting four or more hours in the emergency room.

With results like that, little wonder that the liberals at CAP didn’t want to highlight what single-payer health care would do to our health system.

Socialists Admit Care Rationing Ahead

That said, some socialist supporters of single payer have conceded that the new system will limit access to care. As I noted last year, the socialist magazine Jacobin said the following about one analysis of single payer:

[The study] assumes utilization of health services will increase by 11 percent, but aggregate health service utilization is ultimately dependent on the capacity to provide services, meaning utilization could hit a hard limit below the level [the study] projects.

Translation: People will demand additional care under single payer, but there won’t be enough doctors and hospitals to meet the demand, therefore resulting in waiting times and rationed access to care.

Lest one consider this admission an anomaly, the People’s Policy Project called a recent Urban Institute study estimating the costs of single payer “ridiculous” and “unserious,” in large part because of its “comical assumption” about increased demand for care: “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.” Again, socialists claim that single payer won’t bust the budget, in large part because people who seek care will not be able to obtain it.

With analysts from the right and the socialist left both admitting that single payer will lead to rationed health care, CAP can continue to claim that waiting times won’t increase. But the best response to their cherry-picked and misleading analysis comes in the form of an old phrase: Who are you going to believe—me, or your lying eyes?

This post was originally published at The Federalist.

Pete Buttigieg’s Plan to Tax the Middle Class

Democratic presidential candidate Pete Buttigieg claimed last month that “everything that we have proposed has been paid for, and we have proposed no tax increase on the middle class.” The South Bend, Indiana mayor is incorrect on both counts: He hasn’t said how he’d pay for all his proposed spending. He has endorsed one explicit tax increase on the middle class, and his recent retirement plan provides an outline for another. Add it up, and middle-class workers could face a trillion dollars in new taxes.

To support family caregivers, Mr. Buttigieg’s retirement plan restated his prior commitment to enact “an enhanced version of the Family Act,” which would provide 12 weeks of subsidized family leave. The candidate has yet to specify how exactly he would “enhance” the Family Act. But that legislation, introduced by Rep. Rosa DeLauro (D., Conn.) and Sen. Kirsten Gillibrand (D., N.Y.), pays for its new benefit by raising payroll taxes by 0.2% of income.

Mr. Buttigieg’s retirement plan also contains several new spending proposals, including a long-term care entitlement. He says the program would make benefits available to people over 65 and would “kick in after an income-related waiting period.” His plan cites two white papers as examples of “similar programs” proposed by scholars.

Mr. Buttigieg fails to note how both white papers propose to pay for the new benefits. In the first paper, the Long-Term Care Financing Collaborative envisions a program “fully financed by a dedicated revenue source,” including a payroll tax, “an explicit income tax surcharge, or other dedicated tax.”

The second paper, written by researchers affiliated with the Urban Institute, contains several policy details Mr. Buttigieg adopted, including waiting periods for wealthier people to qualify. That paper also proposes a specific funding source: “an additional tax of about 1.0 percent of earned Medicare-covered income.” In other words, an increase in the payroll tax—a tax increase on the middle class.

The Congressional Budget Office estimated last December that a one percentage point increase in the Medicare tax rate would raise $898.3 billion over a decade. If Mr. Buttigieg intends to fund his new long-term care program via the payroll tax, that tax increase, coupled with the 0.2% payroll tax hike in the Family Act he has already endorsed, would bring total payroll-tax increases to more than $1 trillion.

If Mr. Buttigieg doesn’t want to fund his long-term-care entitlement with the payroll-tax increase proposed in a paper his campaign cited, he should explain where that money will come from. His own claims notwithstanding, Mr. Buttigieg’s candidacy has lacked fiscal candor. His campaign told the Indianapolis Star last month that it had proposed $5.7 trillion in spending to that point, but cited a total of only $5.1 trillion in tax increases and savings.

Mr. Buttigieg’s retirement-security plan has since added other spending proposals with no mention of a funding source. There’s his plan to make those receiving Social Security disability benefits immediately eligible for Medicare, which will likely cost more than $100 billion. There’s his new requirement for state Medicaid programs to cover community-based services as a mandatory benefit, along with mandates on nursing homes—including a $15 minimum wage and higher staffing ratios—which will raise Medicaid spending.

Mr. Buttigieg called Elizabeth Warren “extremely evasive” for her answers on single-payer health care, saying, “I think that if you are proud of your plan and it’s the right plan, you should defend it in straightforward terms. And I think it’s puzzling that when everybody knows the answer to that question of whether her plan . . . will raise middle class taxes is ‘Yes.’ Why wouldn’t you just say so, and then explain why you think that’s the better way forward?” He should follow his own advice.

This post was originally published at The Wall Street Journal.

Warren’s Prescription the Wrong One

In an October analysis the Urban Institute concluded that a single-payer plan, similar to Sen. Warren’s, which eliminates virtually all patient cost-sharing, would raise national health spending by more than 20%, or $719.7 billion a year. In the researchers’ view, the additional demand stimulated by making health care “free” to consumers would overwhelm any potential savings from paying doctors and hospitals government-dictated rates. This higher demand would also raise the cost of single-payer well beyond Sen. Warren’s estimates, meaning middle-class families would face massive tax increases to pay for this spending.

That Prof. Johnson would cite the Urban Institute to argue that Sen. Warren’s plan would lower health-care costs, while ignoring the fact that the institute itself reached the opposite conclusion, speaks to the cherry-picked nature of the proposal, which has drawn derision from liberals and conservatives alike.

This post was originally published at the Wall Street Journal.

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.

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.

In Fourth Dem Debate, Warren Maintains Her Health Care Evasion

On Tuesday, Sen. Sherrod Brown—a notable leftist who has said he supports a single-payer health care system in theory—said in a CNN story that “it’s a terrible mistake if the Democratic nominee would publicly support ‘Medicare for All.’” On Tuesday evening, two of the party’s leading contenders for that nomination, Sens. Bernie Sanders and Elizabeth Warren, redoubled their commitment to such a policy, with Warren drawing fire from all sides about her lack of detail surrounding the issue.

As she had in previous debates, Warren refused to get into specifics about how she would pay for the single-payer plan that Sanders has introduced as legislation, and which Warren has endorsed. Sanders has previously admitted that taxes on the middle class would go up under his plan.

Warren would not admit that taxes on the middle class would go up under single payer. She claimed that costs for the middle class would go down on net under her plan, and that she would not sign any legislation that raised costs on the middle class.

However, even this supposed promise raised additional questions:

  1. Who qualifies as middle class in Warren’s estimation? A family making under $50,000, a family making under $250,000, or somewhere in between?
  2. Does Warren’s promise mean that no middle-class families will see their costs go up on net? If so, that seems like an impossibly high bar to clear, as virtually every major law creates both winners and losers. Even though the left tries to turn the federal government into another version of “Oprah’s Finest Things”—“You get a car! You get a car! You get a car!”—it rarely works out that way in practice.
  3. In September 2008, Barack Obama made a “firm pledge” that he would not raise taxes on families making under $250,000 per year—“not your income tax, not your payroll tax, not your capital gains taxes, not any of your taxes.” That promise lasted for less than a month of his administration. On February 4, 2009, two weeks after taking office, Obama signed a children’s health insurance reauthorization that included a large increase in tobacco taxes—taxes that hit working class families hardest. Given how quickly Obama did an about-face on his campaign promise, why should the American people take Warren’s word any more seriously than they did Obama’s “firm pledge?”

South Bend Mayor Pete Buttigieg also chimed in on the funding discussion. He had previously characterized Warren as “extremely evasive” on the issue during the last debate, and released ads prior to this debate questioning Warren’s and Sanders’ proposals to prohibit private health insurance. During the CNN debate, he pressed both issues, noting (as this commentator has) that Warren has “a plan for everything, except this.” With that, Warren derided Pete’s plan as “Medicare for all who can afford it.”

It seems particularly noteworthy that Warren wants to enact a major expansion of the federal government’s role—the largest expansion of government’s role ever, in both its financial scope and massive reach into every American’s life—yet cannot find a sufficient justification to admit the middle class will pay even a little bit more in taxes to fund this socialist utopia. The former speaks volumes about the left’s ultimate objective—full, unfettered power over the economy—and the latter speaks to the deception they are using to obtain it.

This post was originally published at The Federalist.

“Medicare for All” Would Abolish Medicare

The Aug. 5 op-ed by Rep. Pramila Jayapal (D-Wash.), “The facts about Medicare-for-all,” admirably called for a fact-based debate regarding single-payer health care. But it would help if she accurately represented the facts surrounding her bill — starting with its title — because the legislation has little to do with providing Medicare to all.

Jayapal criticized her fellow Democrats for “incit[ing] fear and sow[ing] confusion” by stating that, under her proposal, “Medicare goes away as you know it.” But a HuffPost article conceded that, “as a point of fact, the Medicare program envisioned under [Jayapal’s bill] is not the program as it exists today.” Moreover, Section 901(a)(1) of Jayapal’s own bill states that “no benefits shall be available under title XVIII of the Social Security Act” — Medicare — after the bill’s new program were to take effect.

A fellow with the Urban-Brookings Tax Policy Center at the Urban Institute recently wrote of the plan from Jayapal and Sen. Bernie Sanders (I-Vt.), “You can call it many things — from ambitious to unrealistic. But please don’t call it Medicare.” That Jayapal refused to describe her own plan accurately should cause readers to question what other inconvenient truths she has ignored regarding her socialized-medicine scheme.

This post was originally published in The Washington Post.

The Fundamental Dishonesty Behind Kamala Harris’ Health Plan

When analyzing Democrats’ promises on health care ahead of the 2020 presidential campaign, a researcher with the liberal Urban Institute earlier this year proffered some sage advice: “We should always be suspect of any public policy—especially when it comes to something as complicated as health care—when anybody tells us everybody is going to get more and pay less for it. It’s really not possible.”

Someone should have given that advice to Sen. Kamala Harris (D-Calif.). Her health plan, a modified version of Sen. Bernie Sanders’ single-payer health care program that she released on Monday in a Medium post and on her website, pledges that it will lead to the following outcomes:

Every American will be a part of this new Medicare system….Seniors will see stronger Medicare benefits than they have now. We will cover millions more people who don’t have health insurance today. And we will reduce costs, save our country money, and ensure that no American has to sacrifice getting the care they need just because the cost is a barrier.

As with Barack Obama’s salesmanship of Obamacare more than a decade ago, Harris’ health plan relies upon the exact strategy the Urban Institute researchers decried of promising everything to everybody. In her socialist utopia, everyone will have coverage—coverage that provides better benefits than the status quo—even as health costs decline dramatically.

Like Obama’s “like your plan” pledge, which PolitiFact dubbed the “Lie of the Year” for 2013, Harris’ plan rests on optimistic scenarios that have little possibility of coming to fruition. But one false premise underpins the entire plan:

We will set up an expanded Medicare system, with a 10-year phase-in period. During this transition, we will automatically enroll newborns and the uninsured into this new and improved Medicare system, give all doctors time to get into the system, and provide a commonsense path for employers, employees, the underinsured, and others on federally-designated programs, such as Medicaid or the Affordable Care Act exchanges, to transition. This will expand the number of insured Americans and create a new viable public system that guarantees universal coverage at a lower cost. Expanding the transition window will also lower the overall cost of the program. [Emphasis mine.]

As any math major can explain, extending the transition window for a move to a single-payer health-care system will not, as Harris tries to claim, lower the overall cost of the program once the entire program takes effect. But it will significantly lower the cost of the program during the transition.

Extending the single-payer transition period to ten years—which conveniently coincides with the ten-year budget window that the Congressional Budget Office uses to analyze major legislation—will keep most of the program’s costs “off the books” and hidden from the public until after her proposal makes it on to the statute books. It also means that her plan wouldn’t take full effect until well after Harris leaves office, meaning she can blame her successor for any problems that occur during the implementation phase.

This fiscal gimmick—delaying most of the spending associated with single payer to outside the ten-year budget window—allows Harris to draw a contrast with Sanders, in which she claims that many middle-class families would not have to pay a single cent in added taxes for all the “free” health care they would receive under a single-payer system:

One of Senator Sanders’ options is to tax households making above $29,000 an additional 4% income-based premium. I believe this hits the middle class too hard. That’s why I propose that we exempt households making below $100,000 [from new taxes to pay for single payer], along with a higher income threshold for middle-class families living in high-cost areas.

Analysts from across the political spectrum agree that the $30 trillion (or more) in new taxes needed to fund a single-payer health care system cannot come from the wealthy alone. Yet Harris proceeds to make that exact argument—that the middle class can have all the “free” health care they want, with someone else footing the bill.

Apart from the fiscal legerdemain, the proposal contains other controversial provisions. While she now claims she would allow private insurance to continue—a reversal of her earlier comments this past January—Harris’ plan states that these insurers would get “reimbursed less than what the [government-run] Medicare plan will cost to operate.” She may tolerate private insurers for the sake of political expediency, but her bias in favor of the government-run plan demonstrates that they would have little more than a token presence in any system of her design.

This post was originally published at The Federalist.