Assume that you are designing a single-payer system similar to Bernie Sanders’ Medicare for All from scratch. Here are some of the major issues, and my analysis:
- Who pays? The Sanders plan relies on a mish-mash of taxes that probably isn’t sufficient to avoid running a substantial deficit. Logically (at least to me), a universal health care program should be paid for by society as a whole, not just by the wealthy, who probably couldn’t afford to bear the entire burden in any event. That means a new tax impacting everyone, like a VAT or a carbon tax.
- Will there be co-pays? The Sanders plan says no, but most universal health plans do include them, partly to defray the very high cost of the plan, and partly to prevent frivolous overuses of the system. Regardless of what Sanders might think, co-pays will almost certainly be included in a single-payer system if one is ever adopted.
- What happens to Medicare? Logic tells you this is a simple question; it would just be folded into the more generous, universal system. Experience tells you something different; the elderly are going to be concerned that the new system will siphon money away from them in favor of younger people who never paid into the system. At a minimum, a huge amount of education and outreach would be required to permit the creation of the universal system.
- Will private insurance continue to exist? As I understand it, Sanders says no, but even the NHS operates with a degree of private insurance. It will be difficult to prevent that from happening here.
- How will the program be sold to workers who currently get insurance through their employer? The success of the new system will depend to a large extent on the willingness of employers to pass their savings on the their workers in the form of higher wages. Will that actually happen? In the real world, it will depend on conditions, and vary from employer to employer. As a result, some workers will be worse off with the new system; it just can’t be avoided.
- How in the world can you get this massive change through a political system that is largely designed to discourage such changes? Regardless of its merits, the obstacles are just too great. Sanders will really need some sort of a revolution to make it happen.