WASHINGTON, DC – Sen. Elizabeth Warren's plan to pay for "Medicare for All" without raising taxes on the middle class departs from how the U.S. has traditionally financed bedrock social insurance programs. That might impact its political viability now and in the future.
While echoing her party's longstanding call for universal health care, the Massachusetts Democrat is proposing to raise most of the additional $20.5 trillion her campaign believes would be needed from taxes on businesses, wealthy people and investors.
That's different from the "social insurance" — or shared responsibility — approach taken by Democratic presidents like Franklin D. Roosevelt, Harry Truman and Lyndon Baines Johnson.
Broad financing through payroll taxes collected from workers and their employers has fostered a sense of ownership of Social Security and Medicare among ordinary Americans. That helped derail several Republican-led privatization efforts. And signs declaring "Keep Government Out Of My Medicare" proliferated during protests against President Barack Obama's health care legislation, which scaled back Medicare payments to hospitals.
The Warren campaign says the reason programs like Social Security and Medicare are popular is that benefits are broadly shared. A campaign statement said her plan would put money now spent on medical costs back in the pockets of middle-class families "substantially larger than the largest tax cut in American history."
But Roosevelt was once famously quoted explaining that he settled on a payroll tax for Social Security to give Americans the feeling they had a "legal, moral and political right" to benefits, thereby guaranteeing "no damn politician" could take it down.
Medicare, passed under Johnson, is paid for with a payroll tax for hospital services and a combination of seniors' premiums and general tax revenues for outpatient care and prescriptions. Truman's plan for universal health insurance did not pass, but it would have been supported by payroll taxes.
"If you look at the two core social insurance programs in the United States, they have always been financed as a partnership," said William Arnone, CEO of the National Academy of Social Insurance, a nonpartisan organization that educates on how social insurance builds economic security.
On Warren's plan, "the question is, will people still look at it as an earned right, or will they say that their health care is coming out of the generosity of the wealthy?" Arnone added. His group takes no position on Medicare for All.
"It's not an accident that Social Security is on the chopping block a lot less frequently than so-called welfare programs," said retirement expert Charles Blahous, a political conservative and a former public trustee overseeing Social Security and Medicare finances.
With Warren's approach, "you are going to have this clash of interests between the people paying the bills and the beneficiaries," Blahous added. His own estimates indicate Medicare for All would cost the government about $12 trillion more over 10 years than Warren projects.
The Warren campaign downplays the role of shared responsibility and instead points to promised benefits under Medicare for All.
"Every person in America will have full health coverage, get the doctors and the treatments they need, and no more going broke over medical bills," the campaign said in a statement. "Backed up by leading experts, Elizabeth has shown how her plan will do this by having the richest 1% and giant corporations pay a little bit more and without raising taxes on the middle class by one penny."
Under Warren's plan, nearly $9 trillion would come from businesses, in lieu of what they're already paying for employees' health care. About $7 trillion would come from increased taxes on investors, wealthy people and large corporations. An IRS crackdown on tax evasion would net about $2 trillion. The remainder would come from various sources, including dividends of a projected immigration overhaul and eliminating a Pentagon contingency fund used for anti-terrorism operations.
Sen. Bernie Sanders list of options to pay for Medicare for All includes a 4% income-based premium collected from most households.
John Rother, CEO of the National Coalition on Health Care umbrella group, said he can follow Warren's argument about making the wealthy pay, but it still looks like a hard sell.
"What is different today is the tremendous gap between the well-off and middle-class people," he said. "In a way it makes sense as a step toward greater equality, but it is still a little tricky politically because you don't have that same sense that 'this is mine, I paid into it, and therefore no one is going to take it away.'" His group has taken no position on Medicare for All.
History records that various payment options were offered for Social Security in the 1930s and FDR favored a broad payroll tax. One competing idea involved a national sales tax.
An adviser's memo in the Social Security archives distills Roosevelt's thinking.
"We put those pay roll contributions there so as to give the contributors a legal, moral, and political right to collect their pensions and their unemployment benefits," Roosevelt was quoted as saying.
"With those taxes in there, no damn politician can ever scrap my social security program," he added. "Those taxes aren't a matter of economics, they're straight politics."