The United States, despite paying the most for health care worldwide, still had 28 million people uninsured in 2017, according to the Census Bureau. Even more are underinsured, and don't have the savings required to deal with a medical emergency, as evidenced by the number of crowdfunding campaigns that regularly go viral. Sens. Bernie Sanders and Elizabeth Warren, two Democratic presidential candidates, want to change that with Medicare for All, a government-regulated health care system that would extend health care to everyone. But the proposal has faced criticism for its potential price tag and the effect it could have on taxes. Experts and advocates tell Bustle that higher taxes are inevitable under Medicare for All — but that’s not necessarily a bad thing. Most people don’t want their taxes to increase, but advocates say it would mean that the costs of health care, especially for women and marginalized people, would ultimately go down. For patients in the U.S. who are forced to crowdfund their care, for example, this kind of change would be literally life-saving.
The Urban Institute, a think tank that conducts policy research, produced one of the highest estimates for Vermont Sen. Bernie Sanders’ Medicare for All plan: about $32 trillion over the first decade. But that would come with benefits to most families. One oft-cited study by the Political Economy Research Institute at the University of Massachusetts Amherst found that, under the Medicare for All bill Sanders proposed in 2017, net health care costs for middle income families would fall by between 2.6% and 14% of their income — that's between $1,560 and $8,400 for a family making $60,000 a year.
Though the PERI study didn't break down savings by demographics other than economic class, women, LGBTQ people, and people of color are likely to see savings on the higher end of that spectrum because they often face higher mental health care costs, higher costs for reproductive health care, and costs associated with chronic illnesses, which they're more likely to have due to stress, violence, and other factors.
Still, the Medicare for All conversation has focused mostly on plans to pay for it, at the expense of the uninsured and underinsured people who can't access care. Warren has faced criticism for hedging on whether taxes on the middle class would go up to help pay for Medicare for All. At the last Democratic primary debate on Oct. 15, she said, “Costs will go up for the wealthy, for corporations. But for middle-class families, it will go down,” according to CNBC.
Katherine Baicker, dean of the University of Chicago Harris School of Public Policy, tells Bustle that the question isn’t whether taxes will have to go up under Medicare for All, it’s whose taxes will it be, and the answer is complicated.
She says that some funding would likely come from a very high progressive tax on the wealthy. And that means very, very high — in the range of 70%. "If you wanted to avoid exorbitantly high tax rates, you would have to tax more people," she says. Under Sanders’ plan, the richest 0.2% of Americans would get hit the hardest by tax increases.
The plan taxes the richest Americans through a marginal tax rate of 50% on income between $2 million and $10 million. He also proposes making the estate tax more progressive, and instituting a wealth tax on the top 0.1%. In addition to taxes on the wealthy, Sanders' plan requires employers to pay a payroll tax, imposes a fee on large financial institutions, and eliminates accounting methods that currently allow corporations to pay less in taxes. His plan calculates that a family of four earning $50,000 a year would save over $4,400 a year under that tax, because they'd no longer be paying premiums or the other out-of-pocket costs they pay in the current health care system.
Baicker says that people's health care costs would go down, "but their taxes in the aggregate overall would go up," depending on how much money they make. She says some people’s total spending, when you add together premiums and cost-sharing and taxes, would go down, but for other very high-income people, costs would go up.
"Women spend a disproportionate amount of their economic resources on health care, so, expanding universal coverage is really essential to women's health and economic security."
Advocates point out that the current conversation about paying for Medicare excludes who exactly will be paying less: women, people of color, lower-income people, LGBTQ people, and other marginalized groups. Sarah Coombs, senior health policy analyst for the National Partnership for Women & Families, which advocates for gender equality through policy and public education, tells Bustle that universal health care like Medicare for All would be particularly important for women. "Women spend a disproportionate amount of their economic resources on health care," she says. "So, expanding universal coverage is really essential to women's health and economic security."
Medicaid, the government health insurance program for low-income people, is the largest single payer of pregnancy-related services in the United States, funding 43% of all births in 2016, according to the Kaiser Family Foundation. But Coombs points out that Medicaid coverage expires in most states 60 days after a pregnant person has given birth, despite the current maternal mortality crisis in the U.S. "We're seeing that women are facing mortality and severe maternal morbidity up to a year postpartum, so it's essential to keep that coverage up to a year," Coombs says. Universal health care like Medicare for All would allow anyone to have insurance regardless of reproductive status or income, meaning that new parents wouldn't lose access to life-saving postpartum care.
Gillian Branstetter, media relations manager for the National Center for Transgender Equality, tells Bustle that easier access to health care would help transgender people in a number of ways. Trans people are more likely to live in poverty due to employment and housing discrimination, among other factors. And poverty, in addition to making it harder to afford care, can create and exacerbate health problems.
"When you're living in poverty, you're also more likely to face a variety of health issues ranging from psychological distress to substance abuse, to HIV, to a sedentary lifestyle, to diabetes," Branstetter says. Trans people more often living in poverty means they're more likely to experience those health problems, "which means we are even more likely or even more desperately in need of a health care system that is affordable," she says.
Stephanie Nakajima, the director of communications at Healthcare-NOW!, which advocates for single-payer health care, says the question of how the country would pay for Medicare for All is too often "framed around a fear-mongering around taxes, and not necessarily about a crisis that focuses on marginalized people who don't have health access."
She says Americans are going to have to confront their "anti-tax bias" if they want to stop people from dying simply because they can't afford care. "If we want to have robust public services, and we want to have a fair economy, then we're going to have to accept that taxes are part of that," Nakajima says. "I think owning the fact that we're going to have to raise taxes is an important part of the conversation as well."
She points out Medicare for All would also raise taxes most substantially on those who can afford it, rather than those who would most benefit from its extended coverage. A health care system that’s progressively funded through taxation “alleviates the burden of health care costs on those who can least afford it, those people who are the sickest, who need the most care, and increases the burden on those who can,” Nakajima says.
She also notes that the United States spends more on health care than countries with universal care, like Switzerland or Australia. But the costs to implement such a system would be high, and Baicker notes that there's still a lot we don't know about what Medicare for All will or should look like.
She says providing adequate health care is much trickier in reality than it is in theory, especially when people who were previously un- or underinsured get health care under Medicare for All and start using it more. "People want to say, 'Oh, the health insurance plan would cover all possible care that people might want,' but that's an infinite amount of care," she says. And with modern medicine, there is a lot of care available with fewer health benefits. "If we don't have a serious conversation about where we want to draw the line on those diminishing benefits, we're going to have a health insurance system that we just can't afford," she adds.
Branstetter says that policy discussions are important and inevitably messy, but that most Americans aren't paying attention to the ins and outs of policy and how something will be paid for. "Most Americans ... want a health care system that is not torturous, that is not arduous, that is not full of needless barriers that serve little purpose but to create profits," she says. "If you ask most people, they just want health care. They just want to be able to know that they can go to their doctor when they need to."