Medicare for All.

Eighteen cents of every dollar spent in our economy goes toward healthcare. Nearly three-quarters of those dollars goes to four places—hospitals, doctors’s offices, prescription drugs, and insurance administration. As of this year, total healthcare spending is expected to exceed $5 trillion. The administration of benefits—policies, claims, coverage, disputes, formularies, accounting for co-pays, deductibles, etc.—employs a lot of people.

So here’s another fun fact. The cost to administer Medicare is similar to the cost to administer benefits in Canada under their single-payer system; it’s around 2%. The cost to administer private insurance benefits in the United States outside of Medicare, is around 13%.

In that delta, there is savings. But also jobs.

That’s why I put Medicare for All behind the development of a Civilian Labor Corps in our non-negotiables. One must precede the other.

Before we go further, let me reiterate a fact that will carry us through this exercise:

Medicare—the public, government-run insurance program—is six times more efficient than the private market.

In other words, the exact opposite of what we’ve been told.

The private marketplace has complicated health coverage in this country beyond anything that is fixable. While most assume that government run operations are bloated and bureaucratic, the Rube Goldberg system of insurance coverage is actually the reason behind the bloat in the healthcare system. And there’s a lot of people feeding off that bloat who would likely be displaced by a single-payer system like Medicare for All.

But as we illustrated in the Civilian Labor Corps essay, most of these administrative jobs are going to disappear over the next decade with the adoption of AI agents; creating efficiencies that would add to corporate profits that would never be passed on to the consumer, because the private market prioritizes shareholder value over the consumer.

Chapter One: Changing the Intent

“Health care as a matter of right, not privilege: No other single idea so captures the spirit of the time. The law did not, in fact, recognize any general right to health care, and philosophers and lawyers questioned what a right to health care or to health itself might require. But despite such objections, the claim was for a time so widely acknowledged as almost to be uncontroversial.” -From The Social Transformation of American Medicine by Paul Starr

Even though Medicare for All (M4A) is third on our list of non-negotiables, I believe it’s the most significant in terms of impact; the impact to our economy, to the labor market, and to the overall signal of intent.

Here’s what I mean by “intent.” Medicare for All is the one policy change that signals a shift in consciousness, in how we view the role of the government and the nature of fundamental rights. Even though we have a notion of general welfare as set forth in the Constitution, the idea of welfare is either expansive in the classical liberal sense or something to be contained under the conservative vision. And because there was no explicit understanding or “enumerated” right to health care when the founders conceived of the theory of welfare, it has been left open to interpretation.

In this spirit, there are two underlying assumptions that must be agreed upon for us to have a productive conversation about Medicare for All.

And I’m explicitly working with the “Medicare for All” framework because it has been demonstrated in polling that this phrase, while interchangeable with national insurance or universal healthcare, is viewed more favorably by Americans.

The first is that healthcare is indeed a fundamental right and not a privilege. So, an acknowledgement that if a society has the means and capacity to deliver care to its population then it has an obligation to do so, and the coverage of said care should be borne by the entire population and not be left to the privileges of employment or any such market force. (Like every other developed nation.)

This shouldn’t be a controversial statement and yet it’s one of the core arguments made against it. But to argue that it’s not a right means that one must then believe it is a privilege.

Conservatives argue that health care can be a right but one that is best delivered by the free market. But when faced with the empirical evidence that the free market is in fact incapable of delivering healthcare coverage at the same scale and level of efficiency as the public market, which is the case, then this argument collapses on its face.

That leads us to the second presumption: corporate healthcare coverage is by nature a contradiction because the incentive structures are wholly misaligned.

If the purpose of a market driven system is to deliver profit, then it is by definition driven by perverse incentives in the realm of general welfare, and specifically health care. Healthcare is designed to prevent and limit interventions and to foster health, whereas the market is driven by the profits related to the volume and scale of interventions.

A similar argument is made in the carceral sphere. You can’t have a private prison system driven by incentives to incarcerate more people. It becomes a self-fulfilling profit prophecy.

Now before we go further, we should also take care to make a distinction between healthcare and healthcare coverage. These two are often conflated so let’s be clear about what we mean. Healthcare is what we receive. Coverage is how it’s paid for. Pretty straightforward. But the latter has a dramatic impact on the former. One of the most important outcomes of Medicare for All is to put healthcare into the hands of physicians; another nuance to the conversation that is often ignored.

But to the broader point, the idea is to leave healthcare decisions in the hands of healthcare providers and provide compensation structures that incentivize care to produce better outcomes. Right now we have a system that prioritizes profits, limits the options a physician has to prescribe modalities of care, and creates barriers to access care on the patient side and compensation on the medical side. All of which has resulted in less favorable healthcare outcomes compared to our peer nations.

Chapter Two: Building the Narrative

One of the themes I’ve been harping on lately is the idea of narratives. The Left in this country has completely lost control of so many narratives that used to inform our movements. We’ve allowed fundamental principles to be co-opted and perverted by the right. Such as:

• A woman’s right to choose
• Voting access
• Diversity and equity
• Union protections
• Liberal education
• Entitlements
• Dignified retirement
• And healthcare

Much of this revolves around the libertarian identity of American individualism as seen through an attack lens against the concept of welfare. The impression of the word welfare is largely pejorative due to decades of attacks from the right. But the very notion of welfare is baked into the DNA of our founding principles. The concept of the American state, a representative democratic republic illuminated by principles of the Enlightenment, is guided by the notion that the government of the United States exists for the general welfare of its citizens.

Because of the broad nature of the term itself, it has been open to interpretation and manipulated by circumstances from war to depression and everything in between. At times, the forces in charge of the prevailing narrative have taken an expansive view of welfare. More recently, this view has narrowed to the limited definition we find ourselves living under today: that the state exists only to protect private property and native born citizens from external threats. Above all else this has been the singular triumph of the neoliberal movement.

Born in 1954 with the passage of Brown v. Board of Education, the neoliberal movement sought to curtail the more expansive definition of general welfare. What began as an effort to preserve the integrity of white male supremacy in our institutions has fully shaped the social, political, economic and environmental landscape of this moment.

The delivery mechanism for the ideology is the fraudulent concept that the free market is more capable of delivering positive outcomes for the masses in all things. Economy. Labor. Protection. The law. Environment. And today’s topic, healthcare. The fantastical notion that a free market is pure and indifferent and therefore only corrupted by imperial governmental interference has been thoroughly discredited by the very circumstances in which we find ourselves. And yet, the government remains the primary scapegoat because we have lost control of the narrative and the meaning of general welfare.

Put simply, our existence on this planet is governed by incentives. And so long as market forces incentivize capital capture and growth at any cost, structures that provide social benefits to all will always be subjected to the will of the markets and the men who control them.

Put even more succinctly, greed is more powerful than the market.

Any system that is designed to benefit the masses cannot be incentivized by profit and control. And yet, this is precisely how healthcare in this country, and only this country operates. The very purpose of healthcare is to prevent, alleviate or cure sickness. Therefore the best outcomes are those that produce good health. Good health in and of itself requires fewer medical and pharmaceutical interventions and fewer hospital stays.

So the question we must pose to those who stand in opposition to something as proven and beneficial as Medicare for All is, why wouldn’t you want a healthy population? In this framing, we can begin to retake control of the narrative because the answers to this are highly predictable and thoroughly debunkable.

Chapter Three: A System Designed to Fail

America’s healthcare system isn’t broken—it’s working exactly as designed. The problem is that it was designed to generate profits, not health outcomes. We spend roughly 20% of our GDP on healthcare, about double what other developed nations spend per capita, yet we have shorter life expectancy, higher infant mortality rates, and leave tens of millions uninsured or underinsured.

In 2021, revenues for the health insurance industry alone topped $1.2 trillion. Or take the story that we did on pharmacy benefit managers (PBMs). The three largest PBMs—middlemen who were originally created just to process prescription claims—took in $604 billion in 2023 alone. Meanwhile, 26 million Americans remain uninsured, with tens of millions more underinsured, and medical debt drives roughly a million bankruptcies annually.

This isn’t failure—it’s extraction. We’ve built a labyrinthine system of profit-seeking entities that add zero value to actual healthcare delivery while siphoning hundreds of billions of dollars annually from the system. From insurance companies to PBMs to hospital administrators, an army of middlemen stand between Americans and their healthcare, each taking their cut while contributing nothing to actual care.

The administrative costs alone are crushing. Hospitals employ entire departments just to handle billing and insurance claims. Doctors spend countless hours fighting with insurance companies over treatment approvals. PBMs manipulate drug formularies to extract larger rebates from manufacturers while pocketing the savings. It’s a system of perfectly legal racketeering.

The most damning indictment of American healthcare isn’t just its cost—it’s that every other developed nation has figured out how to do it better. Whether it’s Canada’s single-payer system, Germany’s sickness funds, or the UK’s National Health Service, other countries have demonstrated that universal healthcare access isn’t just possible—it’s more efficient.

These nations spend far less per capita while achieving better health outcomes across virtually every metric. Their citizens don’t face bankruptcy from medical bills—a phenomenon that exists almost exclusively in America. They’ve achieved this not through some magical efficiency formula, but by recognizing a fundamental truth: healthcare is a public good, not a market commodity.

In these systems, private insurance exists but plays a supplementary role. Moreover, hospitals operate with global budgets rather than fee-for-service models and drug prices are negotiated at the national level.

Conservatives like to pretend that Medicare for All is some radical left idea the Squad proposed along with the Green New Deal. But the fight for universal healthcare in America isn’t new. In 1912, Theodore Roosevelt’s Bull Moose Party platform included national health insurance. Harry Truman proposed a national healthcare program in 1945. John F. Kennedy made it a central campaign issue. Yet each attempt was defeated by a combination of special interests and ideological opposition.

Lyndon Johnson managed to pass Medicare and Medicaid in 1965, but these were always intended as first steps toward a comprehensive national system. We had a shot at something close to national insurance under the Carter administration but the hostile relationship between Carter and Ted Kennedy pretty much killed any meaningful reform. The momentum shifted dramatically under Reagan, who reframed healthcare as a market commodity rather than a public good. Since then, we’ve seen only corporate-driven “solutions” that preserve and enhance the role of private insurance—culminating in the Affordable Care Act (ACA), which, while expanding coverage, further entrenched the power of private insurers.

So back to this idea of healthcare as a right. In an era of modern medicine, it’s difficult to argue that ensuring access to healthcare isn’t fundamental to promoting general welfare. The Founders couldn’t have envisioned modern healthcare, but they understood that certain functions of society transcend individual market transactions.

Just as we don’t require people to pay a private fire department before they put out a house fire, or demand payment before police respond to an emergency, healthcare access shouldn’t be determined by ability to pay. It’s a fundamental right of citizenship in a modern, wealthy democracy.

Chapter Four: Understanding Medicare for All

The most recent Medicare for All bill in the House was introduced by Rep. Pramila Jayapal with 112 co-sponsors. The Senate companion bill was authored by Bernie Sanders.

These bills represent the most comprehensive attempt yet to establish universal healthcare in America. While these proposals gained significant traction during Bernie Sanders’ presidential campaigns and showed strong support across party lines, establishment Democrats—including Kamala Harris who initially supported it—backed away after Joe Biden secured the nomination.

The legislation would establish a national health insurance program to provide comprehensive coverage to all U.S. residents. The transition would occur over a two-year period, with immediate coverage for those under 19 and over 55 in the first year. Unlike current Medicare, this new program would cover:

• All medically necessary hospital services
• Primary and preventive care
• Prescription drugs and medical devices
• Mental health and substance abuse treatment
• Comprehensive reproductive care
• Dental, vision, and audiology services
• Long-term care services and support
• Gender-affirming care
• Emergency services and transportation
• Early and periodic screening for children
• Home and community-based services

Crucially, the program eliminates all cost-sharing. No premiums, deductibles, copayments, or other out-of-pocket expenses would be required. The bill explicitly prohibits private insurance companies from selling coverage that duplicates Medicare for All benefits, though they could offer supplemental coverage for services not included in the program.

So this is where conservatives and even liberals will bring up the costs. How on earth can we pay for all this?

I’m going to address this in two ways. The first is in terms of the funding mechanisms. The second is terms of GDP, or overall expenditures related to administering health care.

Regarding the funding mechanism, paying for Medicare for All relies on a combination of payroll taxes on employers and employees, income taxes on high earners, taxes on capital gains and dividends and a wealth tax on the top 0.1%. A lot of this replaces what already exists on employers and employees. You’re already paying for healthcare if you’re in the private markets, you’re just paying too much and a lot of it is going to administrative bloat and shareholders. So this actually reduces the individual costs and allocates it across the wider income base.

In terms of GDP, we have to recognize the enormous potential savings in administering healthcare means a reduction in total output. I’ll speak to the specifics of this in a moment, but if we accept at face value that eliminating the bureaucratic cost drivers—or administrative profits that aren’t additive to the healthcare delivery model—would reduce the cost of healthcare by upwards of $700 billion annually, then we have to account for this money. Part of it is a shift from profits, which are accumulated by shareholders. But the other piece is in labor associated with the insurers and other middlemen.

One difference in what I’m proposing between the Jayapal and Sanders transition plan, is their bills include provisions to protect workers in the health insurance industry, setting aside 1% of the budget for up to five years to provide wage replacement, retirement benefits, job training and placement and priority hiring for displaced workers. However, I’m on record stating that retraining for the same industry but a different capacity isn’t really a thing. That’s why I’m in favor of implementing a Civilian Labor Corps to broaden the employment base and include services that aren’t competitive with the private sector.

So let’s address the cost savings specifically.

In 2022 Ken Lefkowitz published Medicare for All: An Economic Rationale in which he breaks down the economic impact of a shift away from a market based system to universal healthcare. He takes a composite view of several studies, benchmarks performance against similar international models and concludes that Medicare for All in the United States:

“Saves at least $500–$600 billion a year…allows doctors and other healthcare providers to focus on patients, not administrative issues…and addresses runaway healthcare costs by establishing a cost management structure for the future.” Lefkowitz also notes that, “a base underlying structure is already in place, meaning no massive overall design and infrastructure construction is required.”

In terms of methodology, Lefkowitz cites comprehensive studies that are widely accepted and discounts findings from The Urban Institute, the one major study that is generally used to refute claims made by Medicare for All advocates. I think it’s important to speak briefly to this because it helps us debunk these claims as well in our own advocacy.

Essentially, Lefkowitz identifies a standard and accepted general formula to determine the cost savings or increases under Medicare for All.

Current Healthcare Spending

(Less) savings from reducing insurance company overhead.

(Less) savings from reducing doctor, hospital and other provider administrative costs.

(Less) drug price savings from bulk purchase negotiation.

(Add) costs of new utilization, including doctor visits and hospitalizations.

= New projected spending on healthcare. (Subtract projected spending from beginning spending to obtain total savings.)

According to Lefkowitz, there are four major studies (plus CBO estimates) and they all adhere to this formula. You’ve got the Urban Institute, University of Massachusetts, Yale Epidemiology-Lancet study and Annals of Internal Medicine.

(In typical fashion, the CBO gave a range of cost savings estimates in 2020 of between $40 billion and $740 billion annually. Not particularly helpful.)

The Urban Institute stated Medicare for All would increase spending on healthcare by $700 billion a year, while every other study found the opposite.

• UMass projected savings of $500 billion;
• Yale: $500 billion;
• and Internal Medicine: $600 billion.

So we have to address the discrepancy.

Essentially it comes down to baseline assumptions. The Urban Institute held administrative costs level instead of taking the Medicare and similar international overhead figures. They also projected a surge in utilization of 21%, which is a total stretch. Not only do we have comparable data to analyze in other OECD countries, but we have the pandemic era to compare it with.

The other studies used what they considered to be a high estimate of a 12% increase in utilization, referred to as the Thorpe approach. It’s deliberately high. So the Urban Institute number is almost double the highest assumptions of the other models.

Lastly, they exclude savings on the medical side by not taking physician and hospital administrative costs into account. The bottom line is that the one study used to debunk savings projections under Medicare for All is deeply, deeply flawed.

Non-Negotiable #3.

Hopefully my call for a Civilian Labor Corps makes sense in this context. The last thing we can afford in this economy is to blow a hole in the side of it and bleed out middle class jobs. But accounting for job displacement is just one of the big moving parts to consider if we’re to shift such a big part of the economy. There are imbalances in payments and reimbursements that will need to be addressed as an example. Right now, reimbursements for specialty providers far exceed anything primary care physicians receive. It’s completely upside down and has led to a decrease in primary care.

Then there’s the cost of education, which is crippling for young doctors who are watching their rates get cut year after year while surgeons working twice a week or medical device suppliers rake in millions of dollars each year. As Abdul El-Sayed and Micah Johnson wrote in Medicare for All: A Citizen’s Guide:

“Increasing the number of residency training slots, rebalancing payment rates for primary care versus specialty care, expanding loan forgiveness for primary care trainees, making it easier for physicians who immigrate to the United States to practice here, boosting training opportunities for nurse practitioners and physician’ assistants, and more.”

The Jayapal and Sanders’ bills account for nuances like this and many more such as moving hospitals to global budget payments instead of fee-for-service, empowering Medicare to negotiate drug prices across the board, establishing regional offices to address disparities of care and establishing uniform billing codes and processes.

State and local governments would maintain the ability to provide additional benefits beyond the federal program, though they would be prohibited from reducing coverage below the national standard. The bill also includes specific protections for rural and underserved communities, ensuring access to care regardless of geographic location.

Physicians would have to be at the table rather than the insurance companies and lobbyists who influenced the ACA. Reimbursements, education assistance, approved modalities of care—these are all best determined by those in the industry with the most to gain, the most to lose and the most knowledge. They will make less money overall but it can’t be so much that they lose all hope and incentive to remain in the field. Leveling the playing field between primary care doctors and specialists is one thing; gutting the field is another matter entirely. I say pay them as much as possible given the savings on administration. It’s time to let doctors be doctors, not businesspeople.

The transition to Medicare for All represents both an opportunity and a challenge. While it would save money and improve health outcomes, it would also displace many workers in the current system. This is where the UNFTR non-negotiable labor plan becomes crucial—specifically the creation of a Civilian Labor Corps to absorb displaced workers.

We’re already seeing how AI and automation threaten many administrative healthcare jobs. Under our current system, any efficiency gains from technology will simply increase corporate profits. Medicare for All, paired with a robust labor transition program, offers a path to both better healthcare outcomes and economic security for affected workers.

The choice before us is clear: we can continue to pour money into a system designed to generate profits rather than health, or we can join every other developed nation in treating healthcare as a fundamental right. Medicare for All isn’t just an aspiration—it’s a moral imperative and an economic necessity. The only question is whether we have the political will to make it happen.

In my mind, if we’re to construct a viable future for the Left, our strategy must be anchored by Medicare for All. It’s simply non-negotiable.

Here endeth the lesson.