Medicare for All, the proposal for a U.S. single-payer healthcare system, is one of the most contentiously debated policy proposals in the country today. During the 2020 Democratic primary, debates between candidates often focused extensively on their respective positions on M4A, with progressives like Bernie Sanders and Elizabeth Warren indicating support for it, and centrists like Joe Biden and Amy Klobuchar opposing it. (Pete Buttigieg was for it before he was against it.) Even Donald Trump felt the need to put an op-ed in USA Today warning that “we must win” the fight against the “planned government takeover of American health care” that is M4A.
Unfortunately, it is difficult to have an intelligent conversation about Medicare for All, because there is a great deal of confusion around what exactly it would consist of and what exactly it would do. That confusion is in part deliberate—as former Cigna insurance executive and M4A advocate Wendell Potter notes, the for-profit healthcare industry has spent decades spreading misleading information about single-payer plans, in an effort to sway American public opinion. There is a pressing need to help people cut through the thicket of bad talking points and understand precisely what M4A would mean for them and for the healthcare system.
Medicare for All: A Citizen’s Guide, by Abdul El-Sayed and Micah Johnson (published by Oxford University Press) is a book that should be thrust into the hands of every U.S. legislator, every doctor and nurse, every voter generally. El-Sayed and Johnson bring much-needed clarity and rigor to the discussion about M4A. Their book should be the starting point for every future discussion about the plan. It lays out carefully and clearly why Medicare for All makes perfect logical sense as the next step for reforming the U.S. healthcare system. It explains how M4A would work and why it’s feasible. It rebuts the cheap talking points that have been used against M4A. And, perhaps most importantly of all—and unusually for a policy book—it lays out a political path to getting M4A done, showing that it’s not just a policy that works on paper but something that could happen within the confines of the existing political system. It not only shows us that M4A is good and necessary, but that it is achievable—if (and only if) ordinary people push for it.
El-Sayed and Johnson are highly-credentialed healthcare experts. El-Sayed ran an impressive campaign for governor of Michigan as a progressive, touting a state-level version of Medicare for All he called MichiCare. A former epidemiology professor at Columbia University and director of the Detroit Health Department, he is intimately familiar with the American healthcare system from an academic perspective, a political perspective, and the perspective of a young M.D. who had to oversee a struggling urban health department that had been decimated by privatization. (A story he details in his previous book, Healing Politics.) Johnson, a Harvard Medical School graduate, has published work in the American Journal of Public Health and the American Medical Association’s Journal of Ethics, and cofounded a grassroots medical student organization called Protect Our Patients. (They have both written together about M4A for Current Affairs.) The fact that serious healthcare scholars are laying out an argument for M4A should be enough to show that, at the very least, M4A is a more immediate possibility than its critics admit.
In fact, M4A is a sensible alternative to the existing healthcare financing system, a means-tested nightmare designed to make sure people are getting “the care they want at a price they can afford.” The core problem is that U.S. healthcare costs people far too much money, and isn’t actually very good. In other developed countries, this problem has been solved. In the U.K., for instance, the government simply runs hospitals that offer healthcare free at point of use. The system is wildly popular and frees people of the burden of having to think about money in relation to their medical care. In Canada, the nationwide Medicare system pays for most health services for every citizen and permanent resident. Countries with universal government health plans consistently outperform the United States on a wide number of performance metrics.
M4A simply gives the United States what these countries already have: a financing system that is proven to work. At the moment, health financing is a mess—a mixture of Medicare, Medicaid, employer-based private insurance plans, and plans purchased on the public exchanges. M4A would simplify the system, funding the whole system through progressive taxation rather than a mixture of taxes plus insurance premiums, copays, and deductibles. At the moment, Americans pay a fortune for healthcare, but a large amount of that money is wasted, siphoned off by the shareholders of private insurance companies or gobbled up by administrative costs. (El-Sayed and Johnson note that in an average year, health administration costs amount to $2,500 per American, versus $550 in Canada.)
Medicare for All: A Citizen’s Guide is structured simply. First, it looks at what is wrong with the U.S. healthcare system and why it has been so difficult to fix. Next, it explains how Medicare for All would work and why it addresses the basic problems of the current system. Finally, it looks at how we can actually get M4A implemented despite the range of entrenched interests thwarting the program’s chances of passing Congress and being signed into law.
El-Sayed and Johnson run through the basic dysfunctions of the U.S. healthcare systems—multi-hundred-thousand dollar surprise bills, the search for “in network” providers, protracted negotiations with insurance companies, sudden losses of coverage, the endless confusing bureaucracy. Tragically, they say, among sick Americans under 65, approximately half had trouble affording healthcare, and more than a third of people with serious illnesses spend all or most of their savings on their care. They point out that the current system of providing insurance through employers creates inherent and unfixable problems:
At best, tying health insurance to employment means Americans face red tape and administrative hoops when they move to a new workplace, and they may lose access to their doctors or medications. At worst, it means job loss can trigger a health crisis too, creating a toxic brew of economic and medical damage.
The inefficiency of the current system is astounding. El-Sayed and Johnson cite research showing that “one-sixth of a physician’s work burden is attributable to administrative overhead,” and in one studied hospital “staff spent 73 minutes preparing bills for an average patient,” with “the emergency department [spending] more than 25 percent of its professional revenue simply processing bills.”
But all of this can be solved, and has been solved elsewhere, by just enrolling people in a single government-provided insurance plan. This truly isn’t a radical idea. It’s no more of a “big government” idea than it is to have a single public fire department rather than a series of private fire departments (and private firefighting insurance companies). El-Sayed and Johnson explain that there are six ingredients that make the Medicare For All plan work:
- Universal coverage — M4A guarantees health coverage to every American. [Note: not “access,” but coverage.]
- Comprehensive coverage — M4A guarantees that Americans’ health coverage is comprehensive in terms of the range of covered benefits, the availability of a wide range of clinicians and hospitals, and minimal or no financial barriers to receiving care.
- Pricing power — M4A can wield its considerable negotiating leverage to rein in the cost of drugs, hospital stays, and physician services.
- Administrative efficiency — M4A eliminates the high overhead costs of private insurance companies and reduces the administrative burden on providers and patients.
- Progressive financing — M4A allows healthcare to be financed progressively, replacing the regressive financing of private insurance.
- Public accountability — M4A would be accountable to the American public, rather than shareholders.
So: the single plan would enroll everybody, so that there was no longer a population of uninsured people. It would pay for comprehensive services, meaning that it would include dental, vision, and hearing. El-Sayed and Johnson point out that existing M4A proposals actually offer far more comprehensive coverage than Medicare currently gives seniors, meaning that it is not actually just “Medicare for All” but an expanded and improved version of Medicare. This means that seniors currently on Medicare have good reason to support M4A—no longer would they need “Medigap” policies to fill gaps in their existing government coverage.
Having a single government plan would create a formidable new mechanism for reining in the spiraling costs of healthcare, because Medicare would have the power to set rates unilaterally. This is a good thing, because it would keep for-profit drug companies and hospitals from being able to extort sick people. M4A would also be far more efficient than private insurance, and make life easier for both doctors and patients by drastically simplifying the financing process. By funding healthcare through taxation, the government could ensure that costs were born fairly according to people’s ability to pay. Finally, because the people have some democratic control over the government, unlike private insurance companies, their health dollars are actually being spent by an institution they have a say in the running of, and which exists to serve their interests rather than the interests of profiteers.
El-Sayed and Johnson run through the proposed alternatives to M4A, like Buttigieg’s “Medicare for All Who Want It” plan, and show why all of them fail to satisfy at least one of these criteria. Many, like the plan Joe Biden offered during the primary, leave a portion of the population uninsured, which will lead to unnecessary deaths. Others do not give the government the kind of power to control costs that it needs, or preserve the existing bloated insurance bureaucracy. M4A is the plan that makes logical and financial sense.
The criticisms of M4A are often ludicrous, and depend on trying to trick the public into misunderstanding the plan. So, for instance, pollsters will tell people that they will “lose their insurance coverage” under M4A. But that’s not true. Nobody loses any coverage. They are insured the day before M4A starts and the day after it starts. Their care is being paid for by the government rather than a private company, but they are no less covered. People do lose their private insurance company. But the honest way to explain it is not to say “Would you support M4A if it took away your insurance coverage?” Instead, it’s “Would you support M4A if you maintained the same level of insurance coverage but payments were made by the government rather than a for-profit company?”
Or take the nonsense question, “How will you pay for it?” El-Sayed and Johnson point out the obvious: we already pay for it. You’re paying your insurance company, and if you’re not, your employer is, and the costs are simply hidden from you. M4A isn’t a new expense. It’s simply routing existing expenditures through a public institution rather than a private one. (For an even clearer explanation of this complete with diagrams, see this article.) Opponents of M4A try to delude voters into thinking they will end up with less money under the system by repeating that it will “raise taxes,” without noting that the entire purpose is to save people money, with the increase in taxes more than offset by the savings from not having to pay for healthcare. It should be easy for people to look at the bottom line.
Nor is Medicare for All “socialized medicine,” a phrase that has been used to attack national insurance proposals since the time of Harry Truman’s own failed healthcare reform proposal. It’s socialized insurance. As El-Sayed and Johnson write, it “would change how we pay for care, not who provides care.” (Some more bad arguments against M4A are debunked here.) In fact, the fact that it isn’t socialized medicine is M4A’s most serious flaw—it changes the payment mechanism but leaves the profit motive intact in the actual provision of healthcare (it’s akin to having a public insurance program funding private fire departments rather than a public fire department). But given the system that we have, this mild reformist measure is probably the best near-term improvement we can hope for.
Why is there so much nonsense spread about Medicare For All? Why did liberal Democratic candidates in the 2020 primary spread transparently dishonest talking points, implying to voters that it would leave them uninsured, and telling them of the costs without mentioning the savings? I cannot speculate on motives, but it’s true that Medicare for All does something quite radical. It does do away with a large part of the private insurance industry, just as introducing public fire departments did away with the private firefighting industry. That’s nothing to fear—there’s no reason to preserve bullshit jobs, which siphon away people’s savings, and to keep a useless industry alive for the sake of it.
El-Sayed and Johnson point out that there are “deeply entrenched private interests” that stand to lose financially from Medicare for All, even as the American public as a whole gains. In the final section of the book, on the politics of the issue and the path to succeeding, they warn that the “politics are treacherous,” because insurers, drug companies, and for-profit providers will wage war on the plan and spend a fortune trying to scare the public. There will be swarms of lobbyists, advertising campaigns, and campaign contributions designed to threaten legislators who support the proposal. The conservative think tank network will churn out its usual slick pseudoscholarship, offering phony statistics showing that M4A will make people sicker and destroy hospitals and cost a fortune and so on and so forth. El-Sayed and Johnson speculate that while some Democrats disingenuously “deploy many of the same talking points used by Republican opponents and the healthcare industry,” others just sincerely believe M4A is politically impossible (which becomes a self-fulfilling prophecy).
It’s easy to get depressed about M4A’s prospects, especially as El-Sayed and Johnson review the history of attempts to create a national insurance program, which have been thwarted by industry opposition. But they do not conclude from the record that it is impossible. In fact, there was industry opposition to Medicare itself, but overwhelming public support and organizing was too much for the American Medical Association. If Medicare happened, Medicare for All can happen.
El-Sayed and Johnson point out that there are promising signs for the M4A campaign. It is known to poll very well, even among Republican voters, especially when explained honestly. Furthermore, there are some “swing constituencies” that might benefit from supporting it. Some labor unions have treated M4A as a threat to hard-won union health plans, but El-Sayed and Johnson note that unions should be completely on board, because M4A will mean they don’t have to fight for a good health plan, and can use their bargaining power on other gains for their members. Many large unions recognize this and have already begun to support M4A. Furthermore, many companies both large and small would save money that they currently spend on employee health plans. Sorting out healthcare can be a nightmare for companies (here at Current Affairs, a tiny organization, it’s one of the big headaches when a new worker comes aboard), and M4A would free employers from this burden. Some may end up paying more, and others less, but the many that would pay less have a strong incentive to get behind M4A.
El-Sayed and Johnson note ways to get two key constituencies on board with M4A: seniors and doctors. If seniors are shown that M4A will not just extend to the rest of the population a set of benefits they themselves already have, but also expand their own coverage and eliminate problems with the existing Medicare system, they will have good reason to be on board despite already having Medicare. El-Sayed and Johnson note that while physicians were once seen as consistent opponents of single-payer healthcare (while nurses, who have better politics, supported it), that is changing generationally. Doctors’ professional associations are no longer consistently opposed to M4A, and some—including the American Medical Student Association—even support it. (There is also a group of Physicians For A National Health Program.) Doctors today face a question, write El-Sayed and Johnson: “Will they join Big Healthcare, the conservative infrastructure, and centrist Democratic leaders in opposing M4A? Or will they join front-line clinical workers and the progressive movement in supporting it?” (Ask your doctor if they support Medicare for All. If they don’t, encourage them to pick up Medicare for All: A Citizen’s Guide and ask them to reconsider. Seriously.)
It won’t be easy, but there is a path. Britain, a highly unequal country where the rich have always wielded extraordinary power, managed to get a fully socialized medical system in the 1940s despite industry opposition, because people organized and public pressure on the government was eventually too overwhelming to resist. (The U.K. government’s “Beveridge report” advocating social insurance had proved an unexpected hit among the reading public when it was released, and my hope is that Medicare for All: A Citizen’s Guide can be made similarly ubiquitous, the healthcare equivalent of Paine’s Common Sense.) Change can happen and we can’t be excessively cynical. There will certainly be a massive attempt to mislead people into misunderstanding Medicare for All, but that’s why it’s incumbent upon all of us to be able to demolish these talking points quickly and persuasively so that they don’t catch on. People aren’t stupid. The insurance industry may have money, but propaganda can be countered. We have to make the case for M4A as well as possible, so that the demand for it becomes overwhelming, and politicians fear losing their seats if they don’t support it, rather than fearing the loss of industry contributions if they do. (El-Sayed and Johnson explicitly advocate progressive challenges to incumbent politicians, to escalate pressure on them. We can make it be in their electoral interest to move left.)
The need for M4A has never been more pressing. The COVID-19 pandemic showed that having a giant population of uninsured and underinsured people hurts everyone, and that tying insurance to employment creates massive suffering in times of precarious employment. There is a better and more efficient system available, and we can have it anytime we like. El-Sayed and Johnson’s book is very helpful, because it combines intellectual heft with rhetorical simplicity. It’s straightforward, they say: “most Americans could pay less for better, more secure health coverage.” So why wouldn’t we? The time to demand Medicare for All is now. If anyone doesn’t believe that, give them this thorough and well-argued book. M4A is actually a very modest policy goal, a basic social democratic program of the kind that shouldn’t be considered controversial, let alone radical. Everyone should want to help make it a reality.