Universal coverage would be lobbied against – financing mechanisms are a pipe-dream AND political barriers water down passage.

In the 2016 Democratic presidential primary, Senator Bernie Sanders (D-VT) ran an insurgent campaign against front-runner Hillary Clinton. Sanders's signature proposal was a call to establish “Medicare for All,” replacing the byzantine web of public and private insurance sources from which Americans obtain health coverage—and that leaves millions of people without any coverage at all—with one government-run program. Medicare for All promised to remedy the myriad shortcomings and consequences of America's health insurance arrangements: inequity, inefficiency, insecurity, unaffordability, complexity, poor health outcomes, and more. Sanders's invocation of Medicare for All, rather than the more opaque single-payer insurance label that reformers had previously bandied about, swaddled sweeping change within the familiar grasp of a popular, long-established program (namely, Medicare); instantly conveyed the core, seemingly straightforward idea behind the plan (extending Medicare's federal insurance to all Americans); and, crucially, located the model for reform within the United States rather than across the borders of a foreign country (since the 1970s, American reformers have often touted Canada's universal health insurance arrangements, also known as Medicare, as an exemplar). If, as some critics alleged, it seemed politically or culturally unthinkable and a contravention of American values for the United States to import another nation's national health insurance system (Marmor 1994: 184–85), even one as geographically and culturally proximate as Canada, what was so impossible about building on a Medicare program that had operated in the United States for more than five decades and drew strong support from its beneficiaries and the public?

Sanders lost the 2016 primary to Clinton. However, he did much better than pundits expected, and his Medicare for All campaign raised the issue's profile substantially, far beyond Sanders's voters. In 2016, the Kaiser Family Foundation reported that for the first time, 50% of Americans “favor[ed] a national health plan in which all Americans would get their insurance from a single government plan” (KFF 2020). In the ensuing years, the momentum for Medicare for All grew. In 2017 and 2019, Sanders introduced Medicare for All bills in the Senate (with 14 Senate cosponsors in 2019). Meanwhile, in the House of Representatives Congresswoman Pramila Jayapal (D-WA) introduced similar Medicare for All legislation, with more than 100 members of the House cosponsoring it. Between 2017 and 2020, 53% to 59% of respondents in Kaiser polls continued to favor a national Medicare for All plan, with much higher support among Democrats (KFF 2020).

In the 2020 Democratic presidential primary, Sanders again ran on a Medicare for All platform. This time he was not alone, as Senator Elizabeth Warren (D-MA) proposed her own Medicare for All plan. So too did Senator (and soon-to-be Vice President) Kamala Harris (D-CA), whose conception of Medicare for All maintained, in contrast to other plans, a substantial role for private insurance. Sanders again lost the Democratic presidential nomination to Joe Biden, who supported more modest reform approaches. Yet the substantial media attention to Medicare for All and its endorsement by establishment politicians appeared to mark a shift in US health politics. The idea of replacing America's health insurance maze with one federal government plan enjoyed more prominence in 2020 than at any point since the early 1970s. After decades of presuming that health reform had to preserve private insurance, a growing number of politicians were now embracing the idea of sidelining private coverage in favor of a vastly expanded government role.

For all of the resurgent attention to Medicare for All, though, it often appears as a slogan, with scant attention paid to the different ways in which it could be designed, the related trade-offs, and how such a plan could overcome the formidable political barriers to enactment. Two recent books—The Case for Medicare for All by Gerald Friedman and Medicare for All: A Citizen's Guide by Abdul El-Sayed and Micah Johnson—aim to fill that lacuna. The two books are of a piece; both aim to explain Medicare for All to a general audience, persuade readers of its virtues, and chart a course for turning the dream of Medicare for All into a reality. These books are, refreshingly, clearly written and largely devoid of the dense jargon that typically envelops US health policy, making them accessible to nonexperts, students, advocates, and anyone curious about “what M4A really means, how it works, and what the challenges ahead actually are” (El-Sayed and Johnson 294). El-Sayed and Johnson, in particular, provide an extensive, thoughtful discussion of the various policy options at play, and in doing so they helpfully focus on often-neglected questions of design and implementation while demonstrating that there is substantial flexibility in key dimensions of Medicare for All.

Both books were written at a moment when Medicare for All appeared to be in ascendance. That moment has passed for now, as the Biden administration instead focuses on incremental measures that build on the Affordable Care Act as well as prescription drug pricing and coverage reforms within Medicare. However, Medicare for All is a long-term project, and given the state of US health care and the limits of previously adopted reforms, its appeal will likely endure.

After all, the United States spends more on medical care than any country in the world, yet it is the only rich democracy with a large uninsured population. In addition, the country performs poorly on key health outcomes, including life expectancy and infant mortality. Much of what Americans spend on medical care actually pays for the staggering administrative costs generated by our complex insurance arrangements, which also help to ensure much higher prices for medical services in the United States than in other nations. More than 26 million people in the United States are uninsured, with wide racial and ethnic inequalities in insurance coverage. In a testament to the immense fragmentation and bewildering rules that shape a plethora of coverage pathways, millions of people are eligible for but not enrolled in government-subsidized insurance, including Medicare, where many lower-income beneficiaries do not sign up for financial help with premiums and other costs that they qualify for.

Meanwhile, tens of millions of Americans have health insurance but are inadequately protected against the costs of medical care. If they or a family member require care, they face the prospect of paying high deductibles and copayments/coinsurance that can cause financial distress, lead them to forgo treatment, and burden them with medical debt. Americans with diabetes often ration insulin because of its cost, while many cancer patients suffer “financial toxicity” from their treatment even when they have insurance (Fralick and Kesselheim 2019; Zafar 2016). Insured women can incur thousands of dollars in out-of-pocket costs from pregnancy, childbirth, and postpartum care (Rae, Cox, and Dingel 2022). While the Affordable Care Act (ACA) substantially reduced the uninsured population, during its first decade of operation the number of underinsured persons increased (Collins et al. 2022). In addition, private insurers often reject their enrollees' medical claims, further adding to the insecurity and frustration of the ostensibly insured (Pollitz, Rae, and Mengistu 2022).

The ACA has made important progress in making health care more equitable and secure, but even the most optimistic read of its record would conclude that it has not solved America's health care problems. The pathologies of US health care were again laid bare by the COVID-19 pandemic. A decade after the ACA's enactment, the spectacle emerged of hospitals turning away transfers of patients who were uninsured or had Medicaid (and thus brought those institutions lower payments, making them patients non grata); the loss of employer-sponsored insurance by millions of people as the economy went into lockdown and recession; and medical providers charging exorbitant fees for COVID tests (Evans, Berzon, and Hernandez 2020; Karpman and Zuckerman 2020; Kliff 2021). Clearly, there is much about US health care that is still broken. The ACA did not eliminate the pernicious financial incentives that impede access to medical care and stable health insurance.

The question is whether the myriad shortcomings of US health care can be remedied through additional incremental actions; by continuing to build on and strengthen the ACA; by patching holes, boosting enrollment in existing programs, and reducing inefficiencies in our current nonsystem; or whether more radical action and fundamental change is necessary, namely jettisoning the status quo in favor of Medicare for All.

Both books share the diagnosis that the fundamental flaw in US health care is the predominant role of market forces. Why do we continue to have so many uninsured and underinsured Americans, high costs, and poor health outcomes? “America's unique health care problems,” El-Sayed and Johnson write, “stem from the unique stricture of America's health care system, which is organized around a core principle: that healthcare should be treated as a consumer product” (56–57). Medicare for All “is the only proposal that seeks to transform healthcare into a public good” (212), which from this perspective means it is the only reform plan capable of fixing what ails American health care. “M4A is,” El-Sayed and Johnson note, “a simple policy that expresses a clear moral value: healthcare is a human right” (276).

Similarly, for Friedman, the “ACA has failed to maintain affordability because it does not address the real cost drivers pushing up US healthcare spending: the drive for profits, and the inefficiency this produces in our fragmented private healthcare system” (27). The only way, he believes, to correct the failures of US health care and to achieve universal coverage as well as control spending is to eliminate for-profit insurance. In its place would come a single federal program, Medicare for All, although that is a “misleading title” (7) because it would have a different financing mechanism (moving away from payroll taxes as a major revenue source) and would offer a much more broader set of benefits than the traditional Medicare program (including covering long-term care, dental, and vision services while removing the substantial deductibles, coinsurance, and other cost-sharing payments that Medicare beneficiaries currently are responsible for). That expansion of Medicare's benefit package is a crucial and sometimes overlooked feature of Medicare for All plans: because Medicare's benefits are limited, the vast majority of program beneficiaries have long carried supplemental sources of coverage. Medicare, then, would not simply be extended to the entire population (or nearly so; such proposals often exclude people who receive coverage from the Veterans Administration and the Indian Health Service). It additionally would be transformed into a much more comprehensive form of insurance.

Universal, comprehensive insurance would be accompanied by the administrative efficiencies of having a single insurer, which would also enable price regulation and cost control. If that combination sounds too good to be true, it is only because it is foreign to Americans. Other nations, after all, provide universal coverage of their populations while spending much less on medical care than the United States. The Congressional Budget Office (Nelson 2022), not exactly a bastion of leftist politics or Pollyannaish analysis, found that four of the five single-payer models they analyzed would reduce national health expenditures in 2030 relative to current law (the only version that was not projected to lower total spending included a long-term services and support benefit). There is debate over Medicare for All's short-term impact on the federal budget and health care spending, with some projections finding that it would modestly increase costs (a key question is the level of payments to medical providers) (Katz, Quealy, and Sanger-Katz 2019). Yet there is little question that in the long run such a plan would, via monopsony purchasing, provide the capacity to control health care spending that the United States currently lacks (Fuchs 2018). Moreover, of all the options debated in the United States, Medicare for All is likely the only one that would assure universal coverage.

If Medicare for All offers a compelling reform vision, it also entails surmounting a seemingly insurmountable set of political hurdles. For health insurance companies that would largely be displaced (including a sizable workforce) by such a plan, Medicare for All is anathema that they fiercely resist. Most of the health care industry, from hospitals to pharmaceutical manufacturers, medical device makers, and much more, also strongly oppose Medicare for All (Brown 2019; Oberlander 2016, 2019a, 2019b). After all, they profit from the $4 trillion-plus status quo; any effort to constrain health care spending threatens their incomes (and that of private equity firms, which have a growing financial stake in health care). Additionally, Medicare for All must confront familiar fears about the perils of “socialized medicine” and rationing, including that it will lead to delays in medical care and reduce quality as well as innovation—fears that well-resourced stakeholders can stoke among the public. Then there is the political challenge of shifting private health care spending onto the government budget and raising taxes substantially enough to pay for that sizable shift in a polity with a strong antitax strain that sits near the bottom of rich democracies in terms of government revenues as a portion of the economy (Frakt and Oberlander 2020). In a country historically ambivalent about the role of government, Medicare for All proposes a vast expansion of the federal role in health care that triggers strong ideological and partisan objections.

Moreover, most Americans have health insurance and are satisfied with their present coverage as well as the quality of their own medical care, even as they are dissatisfied with their costs and the system as a whole (Gallup n.d.). By moving people with private insurance into a government plan, Medicare for All would disrupt their coverage, a politically treacherous step. The furor over the ACA's impact on the relatively small individual insurance market suggests that compelling tens of millions of Americans with employer-sponsored plans to switch insurance is likely to ignite a far wider and more intense firestorm.

That underscores a core challenge for Medicare for All. It is premised on the idea that the status quo is fundamentally flawed, necessitating sweeping reforms. Yet the status quo—from employer-sponsored insurance and the ACA's health insurance marketplaces, subsidies, and insurance regulations to Medicaid, Medicare, the Veterans Health Administration, and more—encompasses a mass of stakeholders who benefit from and are accustomed to current arrangements. These stakeholders comprise not only the health care industry and other interests looking to protect their incomes but also insured people. They may fear the loss of their current policies that Medicare for All requires, even if would provide more comprehensive insurance and a better financial deal for many. While private plans increasingly impose large deductibles and other costs that erode the value of insurance, most workers at any given time are healthy and thus may not experience those limitations, diminishing their disaffection from prevailing arrangements and enthusiasm for change.

The political difficulties of uprooting employer-sponsored insurance are well known (and explain why the ACA sought to minimize changes for people with such coverage). However, the existing mix of government health insurance programs creates another barrier to Medicare for All. States that complain loudly about the costs of funding their share of Medicaid are nonetheless unlikely to welcome a plan that sidelines Medicaid and diminishes their role in health policy making. In Medicare itself, the rise of enrollment in private Medicare Advantage plans—which contract with the federal government and will soon cover more than half of beneficiaries—has birthed a large constituency within the program that relies on the extra benefits offered by these plans, which are funded by excessive government payments. In other words, much of the Medicare program is now privatized (as is Medicaid via commercial managed care plans), and that has remade Medicare politics, creating constituencies that benefit from privatization (Kelly 2016). Medicare for All legislation sponsored by Senator Sanders and Representative Jayapal does not continue this private Medicare Advantage component; in such plans, Medicare for All would not only displace private insurance outside of Medicare but also eliminate it inside the program. Opponents of Medicare for All thus charge that it will jeopardize the benefits that enrollees in private plans enjoy. The reality is that with an expanded Medicare benefits package, the need for private supplemental coverage of the sort Medicare Advantage plans offer would be moot. It is perception, though, that often governs politics, and fear of lost benefits is a powerful psychological and electoral force. Even within Medicare, then, the status quo complicates the path to Medicare for All.

Given this litany of steep political barriers—and on top of these lies the fragmented congressional process that frequently dooms legislation to defeat—what strategies have advocates pursued to win enactment of Medicare for All? All too often, there has not been a visible political strategy. Rather, the implicit assumption has been that single-payer insurance can triumph because of its substantive advantages and moral clarity. But that is no strategy at all: if health policy reflected what made the most sense in terms of efficiency or equity, the United States would not have anything like the nonsystem it currently has. Moral outrage, righteousness, and substantive merit do not assure a proposal's legislative success; moral clarity can morph into political absolutism. Bad things do indeed happen to good health care plans in Congress, and there is an inverse relationship between reforms' substantive advantages and their political feasibility (Oberlander 2003). Proposals for a federally run national health insurance system have been around in the United States under varying labels (of which Medicare for All is only the most recent) for more than 80 years. The reality is that the long campaign for national health insurance has been, with the important exception of Medicare's passage in 1965, a failure. At some point, reformers need to reconsider either their aspirations or their strategies.

It is striking, then, that both The Case for Medicare for All and A Citizen's Guide recognize the politically difficult terrain confronting such plans and sketch out road maps for how advocates might navigate toward enactment. El-Sayed and Johnson focus on public opinion, the positions of stakeholders, and above all, the potential of organizing to enhance Medicare for All's political future. They argue (218), “There is one stakeholder in American healthcare that matters most: the American public.” Since “public opinion toward M4A . . . will be deeply influenced by the coalitions lined up on either side of the debate—and how they flex their power” (232), El-Sayed and Johnson conduct a stakeholder analysis mapping which groups support and oppose Medicare for All. The lineups include nurses and progressive organizations in favor and the health care industry, conservative organizations, and centrist Democratic groups opposed. The authors then identify key groups that are in play: “swing constituencies” including “doctors, labor unions, seniors, and large and small businesses” (248) that could influence the outcome of the Medicare for All debate.

EL-Sayed and Johnson are under no illusion that the numerous barriers to enactment will be easily overcome. “Ultimately,” they write, “what will be needed is strong political will within the Democratic party to pursue M4A. . . . M4A will need to become a high priority for Democratic voters and their representatives, and popular enough in swing districts to support Democratic legislators who endorse it. . . . What would it take to strengthen the consensus on M4A and build the political will for reform? There is one foreseeable possibility: a popular national movement pushing for M4A. Quite simply, there is no other force strong enough to overcome the partisan attacks and the deep-pocketed opposition from industry” (275). They cite the large shift in public opinion that presaged the Supreme Court's landmark 2015 decision recognizing same-sex marriage as a constitutional right as well as lessons learned from Bernie Sanders's presidential campaigns.

Do these strategies offer a plausible path to Medicare for All? EL-Sayed and Johnson are surely correct to say that Medicare for All's legislative hopes rest on the Democratic party embracing this platform and gaining sufficient power to enact it. Moreover, as they suggest, if crucial constituencies such as business and physicians moved in the direction of Medicare for All, that could boost its prospects. However, at times wishful thinking creeps into their analysis. There is little sign that a substantial portion of large businesses, who long have been “dogmatic slumbers” (Brown 1993), are on the verge of awakening to endorse Medicare for All. And while there are some progressive coalitions of small businesses, the bulk of those firms and their political associations strongly oppose single-payer plans even though they could benefit them financially (ideological aversion to and mistrust of government as well as fears about taxation shape their stance). Employers are buffeted by rising health insurance costs, but rather than supporting Medicare for All they can raise deductibles, increase employees' costs, or stop offering coverage altogether. Elsewhere, physician politics are changing, as EL-Sayed and Johnson note, with some signs of leftward movement in organized medicine. Yet the political influence of the AMA and other physician associations over US health care policy is much less than it was during much of the 20th century. Even if support for Medicare for All increases among organized medicine—and there is a large distinction between reduced opposition to the idea and active promotion of it—that support may not be politically decisive.

The promise of organizing is central to progressives' political project and identity. At present, though, creating a national political movement for Medicare for All resembles more of an aspiration than a strategy. Same-sex marriage, as remarkable a political and cultural change as it represented, is not a good parallel to Medicare for All. Among other differences, legalization of same-sex marriage did not require substantial new taxes and redistribution, face an entrenched industry, force unwilling Americans to change their own marriage status or, at least initially, have to go through Congress (however, amid concerns that the Supreme Court could overturn its 2015 decision, in 2022 Congress enacted a law enshrining federal recognition of same-sex marriages). And while Bernie Sanders's underdog campaigns were impressive in their capacity to inspire, raise money, and win many votes, he also lost in two successive Democratic primaries. There are steep obstacles to creating the type of national movement that EL-Sayed and Johnson envision, given that most Americans are insured and are satisfied with the quality of their own medical care, and there are real limits to organizing as a strategy to overcome the obstacles that stand in Medicare for All's way.

There are also questions about the role of public opinion in the Medicare for All fight. El-Sayed and Johnson characterize public support for Medicare for All as “high,” (218) referencing a 2018 Kaiser Family Foundation poll in which 59% of respondents favored such a plan. However, that poll was a high-water mark; other Kaiser polls in recent years show somewhat less favorable (although still majority) support for Medicare for All (KFF 2020). Moreover, in those same polls most Medicare for All supporters do not realize that they would have to give up their current insurance coverage; they mistakenly interpret Medicare as All as an option available to all Americans rather than one national plan that all persons would have to join (Oberlander 2019a). In fact, the public option—a new government insurance plan that is open to the uninsured and others—draws much higher support than Medicare for All. And in surveys where Americans are given a choice of different reform alternatives, Medicare for All does not come close to garnering majority support (Holahan and Karpman 2019; McIntyre et al. 2020). There is, then, a temptation for Medicare for All advocates to portray public support for their plan as stronger than it actually is.

Does public opinion have the power to break the political blockade on Medicare for All? “If M4A happens,” El-Sayed and Johnson write, “it will be because the American public decides that we can, in fact, have a more just, equitable, and sustainable system” (292). The American public, though, does not decide public policy. While it is reasonable to argue that stronger public support could weaken the obstacles to Medicare for All, growing support does not, as the authors recognize, guarantee its enactment. Medicare for All advocates could win in the court of public opinion and still lose the legislative battle