Read the Medicare for All Bill and You Will Find Your Insurance Abolished

The best slogan in American health policy is three words long, and it is a masterpiece of marketing. "Medicare for All" borrows the affection of a program that tens of millions of seniors rely on and promises to hand it to everyone else. Who could object to giving everybody what grandma has?

Here is the problem. The slogan describes one thing and the bill describes another. If you read the bill, which almost nobody does, you find that it does not add you to Medicare while leaving everything else in place. It builds a new government plan and then makes it illegal for private insurers and employers to offer coverage that duplicates it. A slogan about expansion hides a bill about replacement.

That is the claim I will defend, in numbered points, from the text. First, though, the other side deserves its best case.

The case for single payer, at its strongest

A fair advocate of a single-payer system would argue as follows.

American health care is expensive, confusing and tied to employment. People lose coverage when they lose jobs. They face surprise bills, narrow networks, prior authorizations and denials. Hospitals and doctors spend huge sums on billing because they deal with many insurers, each with its own rules. A single national plan, the advocate says, would end premiums, deductibles and copayments, cover everyone from birth, allow any patient to see any doctor, cut administrative waste and use its size to bargain down prices. Every other advanced country covers its citizens for less. Medicare itself is popular, and it is not a radical program. It is an American program, and the proposal is to complete it.

That argument has moral force. Nobody wants a family bankrupted by a diagnosis. Nobody defends the confusion of the current system, and many conservatives agree the system is a mess. The disagreement is over what to do about it.

What "for All" actually requires

Start with a plain structural fact. A single-payer system works only if it is, in fact, the single payer. If people can buy private coverage that competes with the government plan, then the government plan has a rival, and it must earn its customers. The designers of single-payer bills know this, and so the bills close the exits.

The Medicare for All Act of 2019 was introduced in the Senate on April 10 of that year by Senator Bernie Sanders (S. 1129), alongside a House bill sponsored by Representative Pramila Jayapal. I am working from the Senate bill, whose text is public on Congress.gov and the Government Publishing Office's site, and I encourage you to read it for yourself. The provision to look for is Section 107, headed "Prohibition against duplicating coverage." In plain terms, it makes it unlawful for a private insurer to sell health coverage that duplicates the benefits provided under the Act, and unlawful for an employer to provide benefits to employees that duplicate them.

That is the heart of it. The bill does not say people may keep their insurance if they like it. The bill says that for the benefits the government plan covers, which the bill defines very broadly, private insurance of the same kind may not be sold.

Six points, from the text

I'll make the argument in numbered points.

1. The bill is a replacement, not an extension. Today's Medicare has four parts, deductibles and copayments, and a large market in supplemental policies and private Medicare Advantage plans. The bill is not "Medicare plus more people." It creates a new, single program with a far wider benefit list than current Medicare, and, in the bill's design, no deductibles, coinsurance or copayments for covered benefits, apart from a capped cost-sharing schedule the Secretary may set for prescription drugs. A new program with a different structure, different benefits and a different payment system has the name of the old one and not much else.

1. It ends private coverage that duplicates the new plan. Because the covered benefits are broad, the category of insurance that would be forbidden is also broad. A person who loved his plan could keep a policy only for services outside the covered list, and the covered list takes in most of what a health policy covers today. "If you like your plan, you can keep it" is a sentence that conservatives have heard before, and I will not rehash that history except to say that this bill is more candid than the sentence suggests. It says you may not keep it.

1. It reaches employer plans. Most working-age Americans with private coverage get it through an employer. How World War II Wage Controls Tied Your Health Insurance to Your Job explains how that arrangement began and The Biggest Tax Break in America Hides in Your Paycheck Stub explains why it stuck. Under the bill's ban on duplicative employer benefits, those plans would end for covered services. Tens of millions of people would move from a plan chosen by their employer to a plan chosen by Congress, over a transition period the bill sets out.

1. It reaches Medicare Advantage. This one is ironic. Medicare Advantage is the private-plan option within Medicare, chosen by a large share of seniors who want extras that traditional Medicare does not offer. The bill bars private plans that duplicate the government's benefits, and its Section 901 provides that no benefits are available under the Medicare title of the Social Security Act for services furnished after the bill's benefits begin, so the program's private option has no future. Medicare Advantage Proves Seniors Will Choose Private Plans When Allowed makes the case that seniors choose it when they are free to. The promise of "Medicare for all" would end the one place where Medicare lets seniors choose a private plan.

1. The financing is left open. The bill sets out a program with no deductibles or copays for covered benefits (drug cost-sharing aside), which means the cost moves to taxes. The text of the bill establishes the benefits and the payment system but does not itself contain a complete tax schedule. Supporters have published lists of possible revenue options, and independent analysts have attempted estimates that differ widely. I will not quote a figure from memory, because the range is wide and the assumptions are contested. Read the Congressional Budget Office and other published analyses and note which assumptions each one makes. The honest summary is that the bill promises more than the country has agreed to pay for, and the people who wrote it say that the price will be offset by savings. That is a claim, not an accounting.

1. The experience of Canada shows what happens when private insurance is banned. I'll take this one at more length.

Chaoulli v. Quebec

In 2005 the Supreme Court of Canada decided Chaoulli v. Quebec (Attorney General). The plaintiffs were a physician, Jacques Chaoulli, and a patient, George Zeliotis, who challenged Quebec's ban on private insurance for services covered by the public plan. Their argument was that when the public system makes patients wait, a ban on buying private insurance to avoid the wait violates the right to life and security of the person.

A divided court agreed, on the basis of Quebec's own Charter of Human Rights and Freedoms. The justices in the majority found that long waits could cause real suffering and that the government had not shown that the ban on private insurance was necessary to protect the public system. In one of the most quoted sentences in the case, Chief Justice McLachlin and Justice Major, in reasons that also found a violation of the Canadian Charter, wrote that access to a waiting list is not access to health care.

Two cautions are needed. The ruling was narrower than its fame: it applied to Quebec, under Quebec's charter, and the justices were split on whether the national charter was also violated. Canadian provinces responded in different ways, and the decision did not dismantle the public system. Do not read it as a verdict that Canada's approach is a failure. I am making a smaller claim. A country that bans private insurance for covered care must reckon with what happens when the public system makes people wait, and its highest court once told one province that it had not reckoned well enough. The proposal in the American bill takes a ban of the same kind and applies it nationwide, to a country with a population many times larger and no tradition of centrally managed waiting lists. Whether the American version would produce waits, and how long, is a prediction, and I will label it as one. But the Canadian court's reasoning is evidence that the question is real.

The answer to the "popular program" argument

Back to the slogan. The advocate says that Medicare is popular and that this proves the country wants it extended. I'd answer in three steps.

First, what is popular is the choice. Seniors on Medicare can add a supplement, choose a Part D drug plan or choose a Medicare Advantage plan. Medicare as it exists is not a pure government monopoly. It is a government program surrounded by a private market. The bill removes the market and keeps the name.

Second, a program that serves one group by design is not a template for the whole population. Medicare serves people over sixty-five, a group the rest of the country subsidizes through payroll taxes while they are working. Extending it to everyone removes the funding base and multiplies the beneficiaries. The financing problem of the existing program is already severe. Medicare's Two Trust Funds and the 45 Percent Warning Congress Keeps Ignoring describes the trustees' own warning. Doubling down on that structure is a strange response to the warning.

Third, people who like Medicare often like it because of what it is compared with: a program that provides a floor for people who would otherwise have trouble finding coverage. That is not the same as thinking the program should be the only option for everybody, including the 30-year-old with an employer plan he likes.

Why a monopoly changes the bargaining

One more argument from first principles, in the manner of Madison.

A government that is the sole buyer of medical services is a monopsony. It can set prices unilaterally, and the supporters of the bill say this is a virtue. It certainly lowers the price the government pays. But prices in any market are signals. They tell doctors, nurses, hospitals and drugmakers where to invest. If the single buyer sets prices below what it takes to supply the service, the supply will be reduced, sooner or later: fewer doctors in some specialties, fewer hospitals in some places, fewer new treatments. The government can respond with rationing or by raising the price, and the bill's defenders say it would raise it as needed. But then the bargain they promised becomes a budget fight, to be settled every year by the political process, and the patient has no alternative to turn to. Price Controls on Medicines Today Mean Fewer New Medicines Tomorrow makes this argument for drugs in particular.

That is where the constitutional point enters. The authors of the Constitution designed a government of limited, enumerated powers precisely so that no single institution would control something as basic to a citizen's life as access to a doctor. Federalist 45 has Madison saying that the powers delegated to the federal government are few and defined, while those that remain with the states are numerous and indefinite. A national monopoly over medicine moves what used to be fifty different decisions into one. Few and Defined, the Promise About Federal Power in Madison's Federalist 45 reads that essay closely. And if you want to see how the other side's reasoning has played out in other countries, eight socialism myths tested against the countries that actually tried it tests the claims against the record.

What conservatives propose instead

The honest conservative position is not that the present system is fine. It is that the way out is to make health care more like the rest of the economy, where prices are visible and people spend their own money on their own choices, and to protect the vulnerable with targeted help. The conservative approach includes expanding health savings accounts, equalizing the tax treatment of individually purchased insurance and employer plans, letting states design their own solutions, funding coverage for the very sick through high-risk pools, and requiring prices to be posted. Four Conservative Health Plans Side by Side, From Tax Credits to Block Grants compares several of those proposals. High-Risk Pools Covered the Sick Before 2014, and They Could Do It Again makes the case for one of them.

These approaches have flaws, and I will not pretend otherwise. They require a patient to take more responsibility, and some will choose badly. But they preserve the thing the single-payer plan eliminates: the ability to leave.

The verdict

A bill that creates a new government plan, bans competing coverage of the same benefits, ends employer plans for those benefits, closes the private option inside Medicare, and leaves the financing to be worked out later is not an extension of Medicare. It is a different system under an old name. People are entitled to argue for such a system. They are not entitled to sell it as something else.

If single payer is a good idea, its supporters should be able to say so in the words of the bill: you will not be able to keep your private insurance for covered services. Let them campaign on that sentence, and let the voters decide.

The case in brief

1. The slogan describes extending a popular program, but the Medicare for All Act of 2019 builds a new program with broader benefits and no cost sharing for covered care, drug schedule aside.
2. Its prohibition on duplicative coverage bars private insurers and employers from offering the same benefits, which ends most private coverage, including employer plans and Medicare Advantage.
3. The bill's text sets the benefits but leaves the financing question open, so the cost and the tax burden are not settled by the bill itself.
4. Canada's Chaoulli v. Quebec (2005) shows that a ban on private insurance raises hard questions when public systems make patients wait.
5. A conservative alternative keeps the ability to leave: savings accounts, more equal tax treatment, state experimentation and targeted help for the very sick.

What you can do: open the Medicare for All Act of 2019 on Congress.gov, find the section on prohibiting duplicative coverage, read it aloud to someone who supports the slogan, and ask them what they think of it.