Would it even look like “Medicare”?
Since the early 2000s, Medicare has been divided into the traditional government program (Original Medicare) and Medicare Advantage. Advantage plans offer the same benefits as Original Medicare plus extras like drug, dental, or vision coverage, but this privatization is known to cost taxpayers an additional $100 billion (!) a year. Meanwhile, seniors on Original Medicare need to buy a separate private plan for any extra coverage.
Medicare has other issues. It leads to overpaying specialists, subsidizing large corporate hospital systems, and leaving drug price negotiation to private plans and pharmacy benefit managers (PBMs).
Medicare for All advocates envision a single, all-inclusive plan with no extra fees or private insurance. This would replace all current programs and set new federal rules for taxes and coverage, making it a way bigger change than just expanding Medicare as it is now.
Would it fix the “broken” fee-for-service system?
U.S. health policy has long viewed high health care costs as the result of overutilization due to the fee-for-service model, where clinicians are paid per test or procedure. This has led to cost-containment measures that reduce use of services, like high deductibles, hospital and insurer consolidations, and prior authorization requirements.
But Americans don’t generally use more health care than people in other wealthy countries. In areas such as primary care, they may even use too little. The bigger reasons U.S. health care costs so much are higher prices for care, high billing and insurance overhead, and spending on costly drugs and treatments that offer little added benefit.
So rather than identifying the problem as fee-for-service and trying to manage utilization, Medicare for All would attack the core drivers of high costs head-on—mainly the prices and the administrative bloat. It’s a very different approach to cost containment.
Could it help small doctors’ offices?
It could.
This part doesn’t get talked about much. Big hospital chains and private equity rollups can charge insurers more than small medical practices can. That’s due to their negotiating power, not the delivery of better care, which forces small clinics to sell to larger chains.
If everyone had the same government insurance with the same set prices, that advantage would disappear. Small, independent clinics could survive without needing to merge into giant systems. Providers would compete instead on quality of care.
This doesn’t mean that corporate health care goes away overnight. Some Medicare for All proposals ban for-profit facilities like hospitals, but many nonprofits have become corporate. This means we need policies to regulate their governance and accountability, regardless of future reforms.
What about rationing and waiting in line for care?
People often say, “if we get government health care, we’ll have to wait forever for treatment, like in other countries.”
Is that true? Not really. U.S. wait times for primary care are longer than in peer countries, on average. While specialty care may take longer elsewhere, access also varies. U.S. access to specialists is quicker than in Canada, but Germany and France have shorter wait times for elective surgery and specialty care. Overall, Americans have the worst access to care among 10 peer nations.
Medicare for All could improve access to care, depending on its goals. Wait times are policy decisions.
But more so, Medicare for All tries to address rationing of access that already exists within the system. Medicaid pays providers much less than private insurance, so fewer doctors accept it, and 27 million Americans remain uninsured. In rural areas, sparse or spread-out populations can make hospitals and clinics financially difficult to sustain, leaving residents with fewer local care options.
High deductibles and copays can lead even insured people to skip unaffordable care. This gets worse every time employer health care costs go up: rising premiums are a flat, regressive tax, eating disproportionately into the wages of lower-income workers.
Medicare for All tries to address these access problems by covering everyone, making care free (or very cheap), and making everyone “worth” the same to providers.
It’s still only a piece of the puzzle.
Medicare for All would certainly be transformative, but changing insurance financing by itself won’t address many of the system’s issues, such as primary care shortages, medical school debt, financialization throughout the system, and much, much more.
And those are just the concerns in the medical system. We know that most of what affects health actually occurs outside of the exam room. That gets into the realm of public health and how our society tackles issues like poverty, education, and access to resources.
But here, Medicare for All plays an underappreciated role because it provides a mechanism for weighing priorities democratically. It allows us to decide whether to allocate more funds to health care versus social programs, for example, and creates a unified budget that we can titrate accordingly.
Bottom line
The U.S. needs solutions to its ridiculous health care costs. No solution will be easy, and no solution will fix it all. Whether the current health care landscape will reach a breaking point that makes Medicare for All a politically viable option at the federal level remains to be seen.
But it does feel like this country is at its tipping point. About time.
Love, YLE and HR-L
Hayden Rooke-Ley, JD, is Assistant Professor at the Brown University School of Public Health. His scholarship focuses on corporate consolidation in health care, Medicare and Medicaid financing, and labor and workforce issues in the health sector. He has published in leading journals, including the New England Journal of Medicine and Journal of the American Medical Association (JAMA), and he advises state and federal policymakers, enforcement agencies, and other health care stakeholders. He is a licensed attorney in Oregon and earned his JD from Stanford Law. His work can be found on X and LinkedIn.