Medicare for All

Paul Francis
8 hours ago
20 min read

Commentary # 38 by Paul Francis

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Introduction

As the summer comes to a close and attention shifts to the midterm general elections, you can expect to hear a lot more about Medicare for All, which was a defining issue for many progressive candidates in the recent Democratic primaries. Because support for Medicare for All became an article of faith for every progressive candidate in the current cycle, it also seems inevitable that Medicare for All will be a defining issue in the 2028 Democratic presidential primaries.

Dr. Sachin H. Jain, a physician, former CMS official, and now the CEO of a Medicare Advantage plan, wrote a very smart article recently titled “Medicare for All Is a Brand, Not A Plan.” The details of both the Medicare for All proposals and the more moderate, Medicare for All-lite alternatives such as a “Medicare Buy-In” are not well understood by the public – and may not be well understood even by the proponents of these policies.

The debate over Medicare for All is emblematic of the divide between the visionary, “progressive” wing of the Democratic Party and the pragmatic, traditionally liberal-to-moderate elected officials that now carry the politically unfortunate label of being the “establishment” wing of the party.

Medicare for All crystallizes a core ideological difference between progressives and establishment Democrats. For decades, the organizing principle of both liberal and moderate establishment Democrats has been strengthening the social safety net on a means-tested basis – concentrating resources on those who need help the most. By contrast, progressives like Zohran Mamdani oppose means-tested benefits on principle, believing that a wide range of government services from childcare to free buses to healthcare are public goods that should be equally available to all comers.

In the case of healthcare, this distinction is reflected in the competing strategies of the Affordable Care Act, with its income-based premium subsidies and relatively high member cost-sharing, and Medicare for All, in which the cost is fully socialized – with no meaningful premiums, deductibles, or co-pays, at least in the most prominent current iterations of Medicare for All proposals.

Congressman-to-be Micah Lasher, the only New York City moderate Democrat with a heavily contested congressional primary this year to come out on top, used healthcare in a recent Substack post to illustrate the dilemma establishment Democrats face against their progressive rivals. As Lasher put it, the left promises that it “will fix – through fundamental change – one of the most visible failures of the American social contract, our broken healthcare system.” Meanwhile, the moderate response “diagnoses what’s broken correctly, and then fails to prescribe solutions that meet the depth of the brokenness….It is hard to persuade people...with a more mealymouthed version of what the guy on your left is saying, even if it’s because you’re being more intellectually honest.”

I happen to think that Medicare for All is not only politically impossible, but would create a one-size-fits-all system that would not be the panacea its proponents suggest. Moreover, the moderate, Medicare for All-lite alternatives that seek to co-opt the Medicare for All brand, such as Medicare for All Who Want It” or a “Medicare Buy-In,” ignore the structural trade-offs involved in designing any insurance system that is not universal in scope. Both approaches distract from the need to reform the underlying healthcare delivery system, which is probably the only way to genuinely improve the healthcare experience in the U.S. in terms of cost and quality.

This commentary describes the major Medicare for All proposals and the main alternatives being offered by more moderate Democrats. I have no pithy policy prescriptions to fix either Medicare for All or its watered-down alternatives, but at the end of this post I will suggest some areas to focus on in terms of reforming the underlying healthcare delivery system. In short, I think meaningfully improving our healthcare system requires not the elimination of most aspects of the healthcare market (as Medicare for All would do), but rather addressing these underlying problems – many of which are attributable to regulatory-capture distortions of market forces – that contribute to the challenges of both unaffordability and lack of access to care in our healthcare delivery system.

Background

It is not an accident that advocates of Medicare for All tend to stay away from laying out a detailed plan. Doing so would reveal how the redistributive impacts of Medicare for All create a vast number of losers even if the policy achieved its fundamental goals of guaranteeing universal coverage without dramatically increasing (and perhaps even modestly reducing) the total amount society spends on healthcare.

A truism of politics is that politicians hate to create winners and losers. Anyone who has worked in government knows it’s much easier to enact across-the-board reductions in spending than redistributive policies that create new “losers,” even if the policy benefits a majority of people. In my view, the inevitable redistributive effects of Medicare for All are so profound that they will continue to render the proposal an alluring but aspirational ideal at best.

Nevertheless, as Micah Lasher’s observation quoted above reflects, the unaffordability of healthcare and dissatisfaction with the current employer-sponsored and insurance-based system are such widespread problems that it’s not surprising that a simple-sounding solution such as Medicare for All that promises to fundamentally change the system seems more appealing than “mealymouthed” changes at the margin. The growing momentum among progressive Democrats for Medicare for All thus creates a dilemma for moderate Democrats who struggle to articulate an alternative.

Given everything that has happened over the last six years, it may be difficult to remember that “Medicare for All” was a defining issue in the 2020 Democratic presidential primary. Bernie Sanders and Elizabeth Warren favored a pure single-payer model with no private insurance. Pete Buttigieg and other candidates struggling to break through into the top tier of candidates sought to appropriate the Medicare for All brand while preserving a larger role for the private sector through a proposal called “Medicare for all who want it”. Only Joe Biden emphasized building on the Affordable Care Act as the most viable pathway to universal coverage.

The divide between visionary “progressives” and more moderate and pragmatic “establishment” Democrats is sharper today than it was in 2020. Based on this year’s midterm Democratic primary elections, we appear to be heading towards a series of litmus tests in the years ahead that will define on which side of the progressive/establishment divide candidates fall. The most charged of those litmus tests at the moment is the candidates’ posture toward Israel, but by 2028 I expect the key litmus tests will include support for a wealth tax and the level of sincerity of support for Medicare for All.

Progressive candidates in recent Democratic senatorial primaries, including Graham Platner and Troy Jackson in Maine, Dr. Abdul El-Sayed in Michigan, Peggy Flanagan in Minnesota, Angie Nixon in Florida) and the three Mamdani-endorsed congressional candidates in New York City who defeated their establishment rivals, used their support of Medicare for All as a key aspect of their political identity. Most of these candidates did little more than sketch how Medicare for All would work in practice, how much it would cost, and how it would be financed. Dr. El-Sayed, who had published a book titled A Citizen’s Guide to Medicare for All in 2021, did somewhat more to explain his proposal, but there was never a real debate about the merits.

New York has long had its own state version of a single-payer system similar to the Medicare for All proposals, called the New York Health Act. The chairs of the New York State Senate and New York State Assembly Health Committees, Gustavo Rivera and Amy Paulin, respectively, continue to sponsor and advocate for the New York Health Act, and the bill has passed the Assembly a number of times. The New York Health Act was routinely endorsed by the Democratic Socialists of America (DSA) candidates who challenged incumbents, in many cases successfully, in New York State legislative races this year.

Although the New York Health Act has been passed by the Assembly (although not since 2018), it has never gained meaningful momentum. As long as the New York Health Act is safely dead on arrival, it will continue to receive at least lip service support from progressives and even from some establishment Democrats, such as Assemblywoman Paulin. If the bill ever threatened to become a reality, New York’s powerful healthcare stakeholders, including both healthcare unions and providers, would vehemently rise up against it.

What Defines “Medicare for All”?

Congresswoman Alexandria Ocasio-Cortez, when asked to explain Medicare for All, has sometimes responded with an answer to the effect of: “You know what Medicare is? Do more of it.” But the major Medicare for All proposals go far beyond Medicare in the breadth of services they cover and the absence of premiums or cost-sharing payments by patients. Traditional Medicare, after all, excludes certain services such as vision, dental, and long-term care, and requires premiums, approximately a $1700 deductible on hospital stays, and a 20% co-pay on most other services unless the individual has purchased one or more Medicare supplemental coverage policies.

In addition, the major Medicare for All proposals provide that coverage would be universal for US residents (without limitations based on citizenship), and services and benefits would be comprehensive (although Bernie Sanders’s Senate Medicare for All bill would leave long-term institutional care under Medicaid). The New York Health Act is similarly universal in terms of eligibility for coverage and offers a comprehensive set of benefits, including all forms of long-term care.

Academic studies of Medicare for All or “universal coverage” models described important distinctions when it comes to both the mode of healthcare delivery and the structure of payment intermediaries. The two basic models for the mode of healthcare delivery are (i) a publicly run system like the UK’s National Health Service (or the Veterans Administration in the US) in which providers are employees of the national system, as opposed to (ii) the arrangement in most countries that have some form of “universal healthcare” under which services are delivered through private healthcare providers but the payment mechanism is centralized.

The two basic payment structures under universal healthcare models that academics evaluate are (i) a single governmental payment entity, such as in traditional Medicare as well as in Canada and the Nordic countries, as opposed to (ii) a multi-payer system in which private insurers compete to administer a publicly financed, publicly regulated set of healthcare benefits with the government setting in payment rates – which describes both Medicare Advantage in the US and the payment systems of countries such as the Netherlands and Switzerland.[1]

With modest differences, the federal House and Senate Medicare for All bills, as well as the New York Health Act model, fall within the paradigm of delivering care through private providers while managing payment through a single-payer governmental entity. All three proposals also prohibit private insurance that duplicates the public benefit, which in practice would make it difficult economically for providers to decline participation in the new single-payer system, because alternatives would be very limited.

How Much Would Medicare for All Cost and How Would It Be Funded?

The prominent center-left economist Paul Krugman posted a Substack piece recently titled The US Healthcare System Is Already Mostly Socialized, in which he argues that Medicare for All is:

“basically calling for an end to the partial, parasitic privatization [by insurance companies] of a healthcare system that is already hugely dependent on public funding. When one looks at it that way, it’s not at all a radical proposal.” (Emphasis added)

That may be one way to look at it. But in practice, Medicare for All changes much more about the healthcare system than the extent to which the federal government is the ultimate payer. In particular, the main Medicare for All proposals would replace the thousands of decision-makers in the sector today (which accounts for 18% of the economy) with a single government-run decision-maker. That strikes me as a radical proposal.

While advocates of Medicare for All are transparent about the benefits of the program, they are cagier when it comes to explaining how much the program would cost and how that cost would be funded. Fortunately, there have been a number of econometric analyses that are clear and accessible and that go a long way to answering these questions. Although many of these econometric studies were prepared in the 2018–2020 time frame, the critical questions and dynamics have not changed: the numbers have just gotten larger with inflation.

A starting point in understanding the cost of Medicare for All proposals is to recognize that total national healthcare expenditures in the United States in 2024 (the most recent reported year) were $5.3 trillion, more than $15,474 annually on a per capita basis and accounting for 18% of Gross Domestic Product. National healthcare expenditures continue to grow at a rate more than double the rate of general inflation, mostly as a result of increased utilization combined with medical price inflation that is similar to the general rate of inflation in the Consumer Price Index. National health expenditures grew by 7.2% in 2024, and CMS projects a compound annual growth rate of 5.6% between 2025 and 2034.

Nearly half of that $5 trillion-plus in national health expenditures is currently funded by the federal government (31%) or state and local governments (16%). In a single-payer system in which all payments are made through a central governmental entity, that means that the federal government would need to raise the amounts currently funded by employers and households through some form of taxation. To put that in perspective, total federal receipts in the current fiscal year will be approximately $5.2 trillion. So in a Medicare for All system, federal tax revenue would need to increase by more than 50% annually to provide sufficient funding to cover the portion of national health expenditures that currently are privately funded.

Of course, most of the spending that new federal revenue would support would result from a shift in private spending by households and businesses. There have been numerous econometric studies analyzing the net impact of Medicare for All on national health expenditures, including studies by the Congressional Budget Office, the RAND Corporation, the Urban Institute, and the Mercatus Center. These studies analyze design features that would increase or decrease the aggregate amount of health spending in a single-payer system, including decisions regarding reimbursement rates paid to providers. The studies generally accept that universal coverage would increase demand and utilization, although they differ on the extent to which supply constraints would limit the actual amount of utilization increase. These analyses all agree that a centralized system would reduce administrative expense, but the extent of those savings varies among studies.

One of the best of these studies is Choices for Financing Medicare for All, prepared in March 2020 by the Committee for a Responsible Federal Budget (CfRFB). The study is particularly helpful in scoring various revenue-raising options. As for the threshold question of cost, the CfRFB study estimated that Medicare for All would require incremental federal spending of between $25 trillion and $35 trillion over 10 years, depending on design choices and policy details.

The CfRFB study identified a number of revenue-raising strategies that could finance $3 trillion annually – a rough midpoint of the incremental revenue that would be needed to fund the policy. These revenue-raising strategies are summarized below:

Impose a 32 percent payroll tax. “The payroll tax would be applied to all wages and divided evenly between workers and employers.”
Establish a 25 percent income surtax on adjusted gross income (AGI) above the standard deduction. “This surtax would effectively increase the bottom income tax rate from 10 percent to 35 percent, the top income tax rate from 37 percent to 62 percent, and the top ordinary capital gains and dividends rate from 20 percent to 45 percent.”
Enact a 42 percent value-added tax (VAT). “The first-order effect of this VAT would be to increase the prices of most goods and services by 42 percent; the VAT would thus represent 30 percent of costs on a tax-inclusive basis.”
Require a mandatory public premium averaging $7,500 per capita – the equivalent of $12,000 per individual not otherwise on public insurance. CfRFB notes that “Though current Medicare for All proposals call for ending premiums, policymakers could consider financing Medicare for All through mandatory fixed-dollar payments to the federal government…. In 2021, we estimate those premiums would need to average about $7,500 per capita or $20,000 per household (including single-person households) if applied to all individuals, including retirees, children, and low-income individuals. Fully exempting everyone who would otherwise be on Medicare, Medicaid, or CHIP would increase the premiums by over 60 percent to more than $12,000 per individual.”
More than double all individual and corporate income tax rates. “Under this scenario, the bottom ordinary income tax rate would be raised to 20 percent, the top ordinary rate would be 74 percent, capital gains would be taxed at a top rate of 40 percent, and the corporate tax rate would be 42 percent.”
Reduce non-health federal spending by 80 percent. “We estimate that financing the full cost of Medicare for All with spending cuts would require cutting the remaining federal budget by 80 percent.¹² Cuts of this magnitude are unrealistically large and certainly could not be imposed on a short timeline.”
More than double the national debt to 203 percent of the economy. “Assuming no changes in projected interest rates or economic growth, deficit-financing Medicare for All over the next decade would require nearly $34 trillion of new borrowing including interest, which is the equivalent of 105 percent of GDP by 2030.”
Enact a combination of approaches. “Rather than identify a single revenue source to finance Medicare for All, policymakers could combine several options.”

The CfRFB study explicitly states that: “There is not enough annual income available among higher earners to finance the full cost of Medicare for All.” At a time when the federal government deficit remains close to 6% of GDP, interest rates are surging due to the nation’s existing $40 trillion of debt, and the reluctance of either party to increase taxes on all but the richest Americans, it strains credulity that Congress would agree to any of these revenue-raising options that full adoption of Medicare for All would require.

The cost of the New York Health Act was scored in an extensive analysis by the RAND Corporation under the sponsorship of the New York State Health Foundation in 2018. The RAND study concluded that, assuming New York would continue to receive federal funding for Medicare, Medicaid, and similar federal programs, New York would need to raise approximately $166 billion in additional revenue in 2026 (which would be about 150% of total State tax revenue today) to fund the New York Health Act. The actual number would likely be higher today than RAND’s 2018 estimate. Bill Hammond of the Empire Center, in response to a recent push for the New York Health Act backed by advocates, suggested an updated study, but truthfully, even the dated RAND numbers make financing the New York Health Act entirely implausible.

Advocates of Medicare for All and the New York Health Act emphasize that this additional tax revenue would offset a comparable amount of spending on healthcare now paid by households and employers. A change in the level of healthcare spending – even if by a few percentage points – is not a trivial matter given the scale of total healthcare spending. The RAND study, for example, argued that the New York Health Act would reduce total healthcare spending in New York by approximately 1%, based on its assumptions regarding administrative savings. But the mechanics of matching up increased taxes with reduced private sector healthcare spending would inevitably create many losers as well as winners.

How would Medicare for All Work?

Irrespective of whether Medicare for All or a state program like the New York Health Act increased or decreased total health spending by a few percentage points in one direction or another, decisions about “how the policy would actually work” would inevitably have profound redistributive effects on both the general public and providers in the healthcare delivery system. This is not to suggest that the healthcare market today reflects perfect economic efficiency. The current system involves significant value judgments and cross-subsidization. But changing that system in a way that dramatically reshuffles the winners and losers reflects one of the ways in which Medicare for All really would represent a “radical solution.”

The widest redistributive effect is whether a particular individual, household, or employer would come out ahead or behind by replacing their existing form of healthcare coverage with the broad-based funding mechanism of Medicare for All. Simply put, would the amount of new tax liability imposed on the affected party be more than what it is paying today, either directly or through an employer-sponsored plan? And would the covered benefits and provider network be better or worse? If Medicare for All reduced the employer contribution to the funding of healthcare, what mechanism would ensure that those savings are passed along to employees to help them pay their new Medicare for All-related tax burden?

If the total amount of per capita spending on healthcare for that group is leveled down, most members of that group will likely see themselves as losers in a Medicare for All system. If spending is leveled up, the total amount of additional revenue that will need to be raised would be at the higher end of the range of total cost estimates by the CfRFB and other economists.

Medicare for All would also have large redistributive effects on the reimbursement of providers within the healthcare system. Indeed, as Dr. Sachin H. Jain points out, even today Medicare has enormous influence on the economics of healthcare delivery. He writes:

“Medicare does not merely pay for care. It sets the relative value of care across the country, and because commercial insurers benchmark to it, Medicare's judgments propagate through the entire system. That fee schedule is the most consequential document in American medicine.”

Nevertheless, while the Medicare fee schedule establishes a benchmark that is almost universally relevant to provider reimbursement, reimbursement rates above that benchmark (and sometimes a discount from that benchmark in the case of providers with little to no leverage) are negotiated outside of traditional Medicare and vary widely among providers. The leading health system or systems in a community, which have real market power, may command reimbursement rates of as much as 300%-400% of the Medicare fee schedule.

The mentality of progressives who advocate for Medicare for All would be to level up reimbursement for the community and safety net hospitals that are struggling financially today, while leveling down reimbursement rates for the leading health systems that deliver the highest perceived quality of healthcare today. Such a redistribution would create lots of losers in addition to many winners among provider groups, as well as among healthcare unions that rely on their negotiations with wealthier health systems to establish the compensation floor for healthcare workers.

A Medicare for All policy should be judged on its merits, not just the political obstacles to adoption. But in terms of those political obstacles, it should be noted that a single-payer system that eliminated the need for insurance intermediaries would be an existential issue for insurance companies. Health and medical insurance companies employ nearly 700,000 people nationally and have significant political clout despite being reviled by a large percentage of the population. Importantly, although polls indicate that a slight majority of Americans have a negative – often very negative – opinion of the healthcare sector as a whole, at least in the individual market, almost 80% of Americans felt good about their own plan options.

What are the Moderate Democrats’ Alternatives to Medicare for All?

Given all the problems with the current healthcare system that advocates claim Medicare for All will fix, what should be the response of moderate and pragmatic Democrats who don’t believe Medicare for All can become reality and would fail if it did?

Although there are some nuanced differences, the three main alternative approaches, each of which could be thought of as “Medicare for All-lite,” take a substantially similar approach: namely, preserve existing employer-sponsored and private insurance healthcare coverage while offering people the option of participating in a plan that shares many of the characteristics of Medicare. The three main alternative approaches can more specifically be described as “Medicare for All Who Want It,” a “Medicare Buy-In,” and a “public option” plan.

Some influential moderate Democratic pundits, such as Matthew Yglesias, seek to blur the differences between Medicare for All and these more incremental approaches, suggesting that they create a “permission structure” for moderate Democrats to take a position short of Medicare for All. Even Dr. Abdul El-Sayed, after his primary victory, suggested he was comfortable with an incremental approach that would ultimately lead to Medicare for All.

Paul Krugman wrote a Substack post recently endorsing a Medicare Buy-in as an alternative to Medicare for All, which as he describes it, would:

“Allow individuals, and possibly more important, employers, to sign up for Medicare benefits, paying actuarially fair premiums to Medicare reflecting the health status of their workers. There’s no obvious reason a public option would be any harder to implement than payments to the Medicare Advantage plans offered by private insurers, which are also supposed to be actuarially fair.”

Matthew Yglesias wrote on his Slow Boring Substack that Medicare for All should be “a floor, not a ceiling,” much like the Australian system in which roughly half the population purchases supplemental coverage with richer benefits than the basic universal coverage system.

At the state level, three states (Washington, Colorado, and most recently, Nevada) maintain what they characterize as public option health plans in their individual marketplaces. Colorado’s public option plan has captured approximately 50% of the individual market by requiring universal provider participation. Without mandatory provider participation, state public option plans have not gained much traction.

These moderate alternatives to Medicare for All, by preserving the existing employer-sponsored and private insurance coverage regime, resolve the enormous political problem of taking away existing options that many people prefer. To the extent that they preserve much of the employer-sponsored and private insurance system, they also reduce the amount of new funding required.

However, by moving away from a universal system, these alternatives run headlong into the core dilemma of healthcare insurance policy: if benefits are comprehensive, the provider network is good, and the premium/cost-sharing is lower than competing private plans, the public plan will attract too many “bad risks” through adverse selection. At that point, the public option plan will fail financially or require exorbitant direct subsidies from government to remain solvent. Alternatively, if the provider network is weak (perhaps because reimbursement rates are insufficient) and the premium/cost-sharing does not meaningfully undercut the competition, few people will choose to join the public option plan.

Significantly, the Medicare for All-lite alternatives do not address the most difficult challenges of this structure. First, the proposals do not specify how provider reimbursement is to be determined and whether provider participation is mandatory or optional. A small state public option plan for the individual market, such as in Colorado, can get away with requiring mandatory provider participation because the number of lives covered (80,000) is too small to dramatically affect the economics of providers. That’s unlikely to be the case with a large national public option model that is comparable to Medicare in scope of coverage.

Second, the Medicare Buy-In and public option proposals do not model the likely cost of the program to the government in terms of direct subsidies or the cost to individuals in terms of premiums and cost-sharing. If the Medicare for All-lite proposals keep the Medicare for All promise of comprehensive benefits without premiums, deductibles, or co-pays, the program would be more attractive than all but the “Cadillac” private plans. Unless private employers are penalized for dropping insurance to take advantage of this generous new federal program, as is the case with the ACA, a high percentage of employers would likely choose to drop healthcare coverage.

These design questions – how much Congress is willing to invest in direct subsidies to make coverage affordable, the extent to which those subsidies should be means-tested, how much cross-subsidization the system will require from those whose health expenses are likely to be lower in favor of those whose health expenses are likely to be higher, and appropriate provider reimbursement levels are the central dilemmas of any regulated health insurance program. The more “incremental” these Medicare for All-lite proposals become, the more they look very similar to the ACA individual insurance marketplace that critics from both the left and the right say has not worked.

It may be that the basic architecture of the ACA is – like democracy – worse than everything except all of the alternatives.

The Gresham’s law of politics is that simplistic solutions drive out nuanced discussion of difficult problems. Tina Brown, who is hardly a socialist flamethrower, wrote the other day:

“The current media trope is that there is a ‘civil war’ in the Democratic Party, but the rise of the new left can also be attributed to the fact that anyone with a pulse hates the milquetoast middle now. On Meet the Press on Sunday, House Minority Leader Hakeem Jeffries ducked and dithered his responses to the question of whether he supported Medicare for all. Compare this to 84-year-old Bernie Sanders’ signature line: ‘healthcare is a human right, not a privilege.’”

The real response from moderate Democrats to the siren call of Medicare for All should be to say that the only real solution to fix the deep structural problems of our healthcare system is to redesign the healthcare delivery system itself. Many of the system’s problems are caused by policy decisions that impede market solutions that would benefit most people but which are blocked by a combination of special interests and an overengineering against risk.

The answer is not to eliminate the healthcare market in favor of a single centralized decision-maker in the form of a single-payer system, but rather to do the hard work of solving discrete problems. Doing so would require taking on the many sacred cows in the healthcare industry. It would require addressing such questions as:

Does global budgeting work, and how can we operationalize it?
Can we use technology to disintermediate expensive parts of the healthcare system that are overengineered against risk?
Can we reduce defensive medicine through medical malpractice reform?
Can we grow the healthcare workforce and improve labor productivity by expanding scope of practice and adding new roles?
Is there a better system for governing claims denials than the current cat-and-mouse game between payers and providers?
Should we insist on greater price transparency and fewer restrictions on health system contracts with insurance plans, such as narrow networks and permitting incentives for directing patients to lower-cost settings, that limit consumer choice?
How can government stop market participants from gaming the system? (In areas ranging from the use of the patent system to delay the introduction of generic drugs to an Independent Dispute Resolution system that encourages specialists to remain out of network in the expectation of gaining above-market prices through arbitration.)

The solutions to these problems don’t fit easily in a campaign platform or social media ad. So until moderate Democrats can come up with a way to better articulate an alternative approach, we can expect that the drumbeat for Medicare for All, as well as facile Medicare for All-lite alternatives, will continue to get louder.

Endnotes

[1] Academic writers have created a more technical framework for comparing universal coverage systems, which was popularized by the journalist T.R. Reid in The Healing of America. This framework sorts countries into four models based on who delivers care and who pays for it. In the Beveridge model, effectively a single-payer national health system, the government does both: it owns the hospitals and employs the doctors, as in the UK's National Health Service or the US Veterans Administration. In the National Health Insurance model (sometimes called single-payer national health insurance), care is delivered by private doctors and hospitals, but a single public payer covers the bill. This is how Canada's system works, and how traditional Medicare works in the U.S. In the Bismarck model, private providers negotiate with multiple insurers, but those insurers are tightly regulated, required to cover everyone, and barred from turning a profit. This “social insurance” model is the system in Germany, the Netherlands, and Switzerland. The fourth model, out-of-pocket, is the default without any central payer, so people pay providers directly. This is closest to what uninsured Americans face today.