As the Affordable Care Act struggles for survival under attack from President Donald Trump and Republicans, many Democrats want to go further than protecting Obamacare by establishing Medicare for All.

Pramila Jayapal, who represents most of Seattle in the U.S. House, is introducing a bill that would provide universal single-payer health care for all Americans. It has garnered more than 100 co-sponsors.

Most Democratic presidential candidates support some form of universal coverage, too. Some, such as Sen. Bernie Sanders, would eliminate private insurance. Others back the general idea but wouldn’t go so far. One step would allow people to buy into Medicare at age 50.

A poll by the Henry Kaiser Family Foundation showed 56% of respondents favor some form of single-payer coverage. This compares with about 40% at the turn of the century.

Even so, Medicare for All is unlikely in the near term. Republicans, who have a lock on the Senate and Supreme Court, are vehemently against it. So are the powerful medical, insurance and pharmaceutical lobbies. A Democratic House majority is not guaranteed if members in swing districts are tarred as “socialists.”

But this is a long game. Attitudes may shift, particularly if young people hold on to their liberal positions. They face a future of continuing sharp cost increases for health care — and a future where technology eliminates an ever-larger number of traditional jobs that provide health insurance. As millennials health needs rise, they may be less supportive of spending more on defense than the next eight nations combined, less supportive of tax cuts for the wealthy and corporations.


History may be a guide. Federal laws for food and drug safety were impossible until Americans’ minds were changed by muckraking journalism and Upton Sinclair’s famous novel about the Chicago meatpacking industry, “The Jungle.”

Social Security was a fringe idea until the suffering of the New Deal.

Ronald Reagan denounced Medicare proposals (“socialized medicine”) in 1961, but actual Medicare was too popular for him to dismantle as president in the 1980s.

So rather than magical thinking that a progressive presidential candidate can defeat Trump — no sure thing — and instantly proclaim Medicare for All, let’s look at the practicalities and economics.

Today’s fractured system delivers excellent care — for those who can afford it. Even so, Americans pay far more for prescription drugs and many other health services than is the case elsewhere.

From 1997 to 2017, health-service costs rose about 250% compared with 56% overall inflation. Even with Obamacare, 28.5 million, or 8.8% percent of the population, lacked health insurance in 2017.


Under Medicare for All, the federal government would pay for all or most health care. A New York Times survey of studies examined the proposals. Under current law, Medicare and Medicaid cost the government $1.4 trillion a year. This could rise to anywhere from $2.8 trillion to $3.9 trillion under single-payer. Much of the difference in cost projections depends on better administrative efficiencies and lower drug prices.

Even using the least expensive forecast, “federal spending on health care would still increase by 10% of GDP, or more than triple what the government spends on the military.” Tax increases might hit the middle class, not just the rich.

What we would get, in theory, is universal access — no small thing. It’s a given in every other advanced nation. Single-payer would also be a competitive advantage, with American companies no longer bearing such high costs of insuring employees. And the sticker shock implied by the number above needs to be offset by experience elsewhere — and success in lowering costs.

Health-care economist Victor Fuchs estimated that if the United States could bring its health-care expenditures in line with other “high-spending” nations (18 percent of GDP vs. 12 percent), it would free up more than $1 trillion annually.

Universal systems enjoy much lower costs than is the case in today’s American system. Canada is one example, providing better care at lower cost, but physicians still enjoy the same autonomy as their colleagues in the United States. (Likely they enjoy more, as American docs spend ever more time arguing with insurance companies.)

Sandro Galea, an emergency physician and dean of the Boston University School of Public Health, wrote in the Harvard Business Review: “If implemented correctly, a centralized payment structure can create a health care system that is genuinely organized around health.”


Today’s U.S. system is organized around increasing profits, marketing and developing advanced drugs and treatment available to only a fortunate minority.

Still, Fuchs offers some nuances and cautions in an article for the Journal of the American Medical Association.

“To have any chance of success in the United States, single-payer would have to be simple, require a minimum of bureaucracy, be based on decentralized organizations to provide care and provide opportunity for individuals to choose among competing health plans,” he wrote.

Also, “No country achieves universal coverage without subsidies and compulsion. The United States could achieve universal coverage relatively promptly if it were willing to adopt these 2 principles.” Yet Americans have been divided about this even with Obamacare.

We’re not at a consensus on universal coverage yet. But that doesn’t mean never. Events are moving fast, and often surprisingly. So don’t be quick to write off Medicare for All, or dismiss it without studying the details.