Medicare for All Won’t Bring Medicare to All

While single-payer is quite different from other health-care proposals, it’s also very different from Medicare itself.

Self-proclaimed “progressive Democrats,” including the doughty left-handers of the Democratic Socialists of America, are on a bit of a roll right now, and are justified in pushing back against ancient intra-party and MSM claims that their agenda is too radical for the country. But that doesn’t mean they aren’t capable of a dubious argument, as is evidenced by a piece in Vox in which two DSA health-care activists cry foul over the appropriation of the term “Medicare for All” by centrists who don’t actually support a leap to single-payer health care. Here was their objection:

[A]s public support for Medicare-for-all rises, establishment think tanks and lobbyists are floating proposals designed to capitalize on its momentum while diluting its content.


In February, the Center for American Progress released a plan called “Medicare Extra for All,” a particularly shameless attempt to co-opt Medicare-for-all’s popularity …. [I]t would allow people to buy into a public “Medicare Extra” plan while leaving in place the privatized, multi-payer system that drives our health care struggles.

To separate the sheep from the goats, these DSA folk identify a number of “core demands” for any genuine Medicare for All proposal, which they identify with legislation offered by Senator Bernie Sanders and Representative Keith Ellison. But while these “demands” are perfectly legitimate criteria for a single-payer system, in some respects they simply underline the extent to which Medicare for All is an inaccurate label which has been appropriated by single-payer fans.

Here’s the very first “demand”:

We need a true single-payer system, not a patchwork. Unlike our current fragmented mess of a health care system, Medicare-for-all would ensure that Americans no longer have their health outcomes determined by the free market’s whims.


It would expand Medicare to everyone as a single, public program and prohibit private insurers from offering competing services, effectively abolishing the private health insurance industry altogether and democratizing approximately one-sixth of the US economy.

But that’s different from Medicare itself. An estimated one-third of Medicare beneficiaries choose “Medicare Advantage” plans offered by those private health insurers that single-payer advocates want to shut down, and that’s after the Affordable Care Act got rid of subsidies Republicans had created to make private plans more attractive. So providing Medicare for All would involve a pretty radical change in Medicare as we have known (and loved) it. That’s true also of another “demand”:

Everything covered under Medicare-for-all will be provided without cost, meaning no fees, no copays, and no deductibles. Medicare-for-all isn’t “affordable access” or the opportunity to pay for care; it’s care without any financial hurdles at the doctor’s office, clinic, or hospital.

Medicare itself has premiums (for Part B non-hospital coverage and Part D prescription drug coverage, anyway), co-pays, and some deductibles. Some might argue that no one dealing with these cost-sharing burdens would mind seeing them go away, but they are part of what makes the whole program fiscally sustainable — and also an “earned benefit” (it’s only partially that, but is most definitely perceived as earned by many beneficiaries) rather than “welfare,” which is an element of its popularity. Again, making these radical changes in Medicare while purportedly just making it available “for all” involves some serious sleight-of-hand.

But there is one respect in which single-payer actually seems to change Medicare in a beneficial way — but really doesn’t. This is perhaps the biggest howler in the DSA argument:

If we are truly committed to the idea of health care as a right, then we will eliminate the profit motive and guarantee that all patients receive the same standard of treatment and breadth of coverage.

There is nothing about single-payer that inherently does a single thing about far and away the biggest profiteers in the health-care system, which are not insurers but providers, as Phillip Longman has pointed out:

Adopting a single-payer system might have done a lot of good — twenty years ago. But since then, a massive wave of corporate consolidations has transformed the American health care delivery system in ways that make the single-payer approach highly problematic. Most Americans now live in places where there is little or no competition among medical providers. In market after market, hospitals, clinics, physician practices, labs, and other key health care infrastructure have been merged into monopolies controlling nearly all aspects of health care in the areas in which they operate.

Thus, without additional reforms, single-payer could wind up enabling a massive set of corporate subsidies in the name of, well, democratic socialism.

In any event, those who wish to use “Medicare for All” as a descriptor for anything other than a simple expansion of the current program to make it universal have no particular standing to lecture others that they are misappropriating the term. In the long run whatever progressives lose from not fully exploiting the popularity of Medicare they might well gain from better public understanding of what they are actually proposing, with all its costs as well as benefits.

Medicare for All Isn’t Single-Payer Health Care