Democratic presidential candidates attempting to appeal to progressive voters calling for a “Medicare for All” plan are struggling 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.

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.

U.S. Sen. Kamala Harris, D-Calif., speaks at the AARP Presidential Forum at the Waterfront Convention Center in Bettendorf, Iowa on Tuesday, July 16, 2019.  (Olivia Sun/The Des Moines Register via AP)
U.S. Sen. Kamala Harris, D-Calif., speaks at the AARP Presidential Forum at the Waterfront Convention Center in Bettendorf, Iowa on Tuesday, July 16, 2019. (Olivia Sun/The Des Moines Register via AP)

“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 think tank. Democratic candidates campaigning on “Medicare for All” should offer more specificity about how they would finance it, Holahan added.

Sanders is 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.

However, Sen. Joe Manchin (D-W.Va.) embraced the GOP’s line of attack on “Medicare for All” proposals, arguing that the government can’t even pay for the program it has now.

“We can’t even pay for Medicare for some and to go Medicare for All, we can’t take care of those who are depending on it right now,” Manchin said at The Hill’s Future of Healthcare Summit

Kamala Harris, who has repeatedly tried to clarify her position on Medicare for All, vowed last 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.”

Democratic presidential candidate U.S. Sen. Michael Bennet, D-Colo., speaks during a meet-and-greet event at The Smokestack in Dubuque, Iowa, on Sunday, July 14, 2019. (Jessica Reilly/Telegraph Herald via AP)
Democratic presidential candidate U.S. Sen. Michael Bennet, D-Colo., speaks during a meet-and-greet event at The Smokestack in Dubuque, Iowa, on Sunday, July 14, 2019. (Jessica Reilly/Telegraph Herald via AP)

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.

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 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, he 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.”

According to the White House, the American middle class would face a massive tax hike to cover the $32 trillion price tag. “Doubling all currently projected federal individual and corporate income taxes would be insufficient” to pay for this single-payer system, George Mason University’s Charles Blahous said.

President Trump said, “We oppose efforts from Democrats to raid Medicare to fund socialism, robbing seniors of their benefits.”

Includes reporting from the Associated Press.