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Updated 5 years ago

What is 'Medicare for All' and how would it work?

The far-reaching health care proposal has touched off a fierce debate. Here’s an explanation of what it is and where the candidates stand on it.
Illustration of a voter casting a ballot in a box full of medical supplies.
Many Democratic presidential candidates back some version of "Medicare for All." But there are big differences in what they mean by it.Adriana Bellet / for NBC News

The highlights of the plan

  • A single-payer, government-run health care program in which all Americans are covered and which replaces almost all other existing public and private plans.
  • Many Democratic presidential candidates back some version of "Medicare for All," although there are differences in their approaches.
  • Supporters say it’s the best way to cover all Americans and hold down the costs.
  • Critics say the cost will be astronomical, ask how it will be paid for, and question whether the government can effectively manage such a massive undertaking.

The nuts and bolts

"Medicare for All" typically refers to a single-payer health care program in which all Americans are covered by a more generous version of Medicare, the health-insurance program for the elderly, that would replace all other existing public and private plans, with few exceptions.

Several 2020 Democratic candidates have campaigned on instituting single-payer health care. Other candidates have described a single-payer health care system as a broad goal and even co-sponsored Medicare for All legislation in the Senate and the House, but have campaigned on less-sweeping alternatives. This can make discerning their position confusing, especially because some argue that their incremental approach will eventually lead to Medicare becoming the default insurance option.

Under a single-payer bill sponsored by Sen. Bernie Sanders, I-Vt., Medicare for All would cover essential treatment with no premiums or deductibles. It would also expand the categories of benefits under the current Medicare system to include areas such as dental and vision coverage, as well as long-term care.

After a four-year transition, private insurers would be barred from selling plans that offered similar coverage, effectively banning them as an alternative. Instead, private insurers could offer supplemental plans that cover items excluded from Medicare, such as cosmetic surgery. Some federal health programs, such as the Veterans Health Administration and Indian Health Service, would continue.

There are several different versions of Medicare for All, including a separate House bill sponsored by Rep. Pramila Jayapal, D-Wash., with 112 co-sponsors, all of them Democrats. Many Democrats also back more modest proposals — which they sometimes also refer to as Medicare for All — that would expand access to Medicare and Medicaid without ending the private insurance system the way that Sanders’ plan and similar ones would. Most of these alternatives involve allowing individuals or employers to purchase a Medicare-like “public option,” a government insurance plan that would compete with private plans rather than replace them.

How it’s different from Obamacare

President Barack Obama pursued a different approach with the Affordable Care Act, which focused on covering people who were unable to get insurance through their job or existing federal programs.

Under the ACA, the government offered subsidies for individuals and families to buy private plans through a government exchange. It also expanded Medicaid, the program for low-income people, to cover more Americans.

Supporters of Medicare for All argue the ACA’s approach didn’t go far enough. While the law broadened coverage to millions, about 27 million people are still uninsured, according to the Kaiser Family Foundation, and there are signs that number is growing.

The ACA’s exchanges have struggled to attract insurance companies, leaving many areas with few choices of plans, although none with zero options. Customers who make too much money to qualify for subsidies have sometimes found the plans unaffordable, while others have complained that deductibles, while capped under the law, are still too high.

Why supporters like Medicare for All

Proponents of a single-payer Medicare for All argue that health care is a right and that enrolling all Americans under one plan is the best way to ensure universal coverage, especially for economically vulnerable populations.

For those who do have insurance through their job or through an individual plan, deductibles are rising faster than wages and customers can face surprise hospital bills from out-of-network doctors and specialists.

By ending the use of employer-sponsored insurance as a primary source of coverage, Medicare for All would also free Americans to change jobs without losing their existing plan and health care network.

Americans spend far more on health care per person than other developed nations and supporters of a single-payer plan argue it could hold down costs by negotiating or requiring lower payments to doctors, hospitals and drug companies, while eliminating overhead associated with private insurance.

As a result, even though the government would spend much more on health care under Medicare for All than it does now, supporters argue that a single-payer system might reduce total national health spending by some estimates and that money currently going to premiums would help offset the new taxes on individuals and families.

Similarly wealthy countries tend to have both universal coverage (though not always a pure single-payer system) and healthier populations than the U.S., suggesting there’s a workable path to guaranteeing health care. Medicare for All plans in the House and the Senate would be more generous than universal plans in other countries, where citizens are often expected to shoulder more out-of-pocket spending or take on supplemental private insurance, which would raise its cost to the government.

What the critics have to say

The high cost is one of the most common arguments against Medicare for All. The nonpartisan Congressional Budget Office has not yet determined how much single-payer legislation would cost, but some outside analysts have tried to gauge its potential impact.

One 2018 study by the RAND Corporation estimated that federal spending on health care would increase from $1.09 trillion per year to $3.5 trillion under a single-payer plan similar to legislation in Congress. Politicians backing single-payer bills have so far been reluctant to explain how they would pay for their plan and it’s difficult to tell which individuals would pay more for care and which less without more details.

Leading health care industry groups have formed an umbrella organization called the Partnership for America’s Health Care Future to lobby against Medicare for All, both single-payer and more incremental proposals, and they warn that cutting payments to providers could affect hospital care and attract fewer doctors and specialists. Private insurers currently pay more, sometimes much more, for medical services than Medicare does. Setting payment rates under a single-payer plan could be a tricky balance: too low and they might make services worse, too high and they’ll make the new system even more expensive.

Conservative critics are more skeptical of the government’s ability to administer coverage on such a large scale, pointing to longer wait times for certain care in some countries with single-payer systems. Moving to a single-payer system would also require decisions about whether the new Medicare plan would reimburse providers for abortion (which federal programs are currently barred from covering) and whether it would include undocumented immigrants.

Many liberal-leaning critics are concerned that the transition to single-payer would be too disruptive, given that about 155 million people receive health coverage through their employer, an issue a number of Democratic presidential candidates have raised. Most people who get employer insurance report being satisfied with their plans and could be upset if they’re required to join a new government program instead.

Democrats who oppose single-payer tend to favor making a Medicare-like plan optional instead. There are numerous competing bills and proposals for a “public option” plan or “buy-in” to Medicare or Medicaid that differ in how many individuals or businesses would be eligible to participate and how the government plans would function.

What the 2020 Democratic candidates — and Trump — are saying about it