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Is health care a right or a privilege? That question dominates our thinking about U.S. health policy and often shapes critical political choices. Unfortunately, it also prevents an honest discussion about the trade-offs in health coverage. If you believe health care is a right, how do we pay for universal health care? If you view health care as a privilege, what happens to the millions of uninsured Americans?

Take the Medicare for All bill (S. 1804) introduced by Sen. Bernie Sanders. Its primary benefit is universal health coverage without any direct cost to individuals. This would be an incredible achievement, especially for the nearly 30 million uninsured individuals in the U.S., whose lack of coverage leads to approximately 45,000 deaths a year.

Even for Americans with health insurance, the system needs reform. The past five years have seen premiums double and deductibles increase 40 percent. Many health insurance plans have narrow insurance networks that cover only a limited number of providers and hospitals. These often add more costs in emergencies, especially when the closest hospital is outside the network. According to the Federal Reserve’s 2017 economic well-being report, nearly half of Americans have less than $400 in savings, making the high cost of health care even more problematic.


To fully assess Medicare for all, it is essential to consider how it affects all stakeholders in the health care system — the uninsured, the insured, health care providers, insurance companies, and taxpayers. Progress for one may be losing ground for another.

Medicare for all would achieve universal coverage, a great outcome when viewed through the eyes of the uninsured. But consider its impact on others. It would likely result in longer wait times for the currently insured because of new demand from the uninsured. While health systems would likely eventually hire more providers, they cannot immediately adjust to new demands. In addition, the supply of physicians may be constrained as premed students may adjust career plans in response to anticipated cuts in reimbursement and rising student loan debt.


Medicare for all would also affect individuals who work in the health care industry, which employs a lot of people. In fact, more people work in health care than in either the manufacturing or retail industries. During the recent recession and economic recovery, the health care sector added jobs every month. And although expanded coverage provided by Medicare for all might lead to more jobs in patient care, the likely elimination of private health insurance could result in the loss of half a million jobs. A temporary work assistance program is included in Sanders’ Medicare for All bill (see page 45) to support displaced workers, but many would struggle to find new employment.

Medicare for all would also affect the broader economy, particularly large health care organizations that account for approximately 18 percent of our gross domestic product. Three of the Fortune 10 — UnitedHealth Group, McKesson, and CVS Health — are health care companies and four of the others — Walmart, Berkshire Hathaway, Apple, and Amazon — have current or proposed health care initiatives. Though the stocks of large health insurance companies grew twice as much as the S&P 500 since the Affordable Care Act was passed, this growth was largely due to private and public approaches to expanding coverage. A public-only version of reform might not be so friendly to growth.

While CVS Health and McKesson would likely do well with increased demand for health care, UnitedHealth Group would need to significantly adjust its strategy so as to not suffer dramatically upon the elimination of private health insurance. Under Medicare for all, much of the added cost of providing health coverage would be financed through an increase in the payroll tax from 15 percent to 45 percent, which itself could increase unemployment. The Health Care Select Sector SPDR (XLV), an index that seeks to represent the health care sector within the S&P 500 Index, fell 2 percent after a federal judge in Texas ruled that the Affordable Care Act was unconstitutional. The drop highlights shareholders’ outlook on dismantling the current system.

If enacted, everyone would feel the consequences of Medicare for all — some would be positively, others negatively.

Morally, it is a grave failure that lack of insurance coverage and high prices restrict so many Americans’ access to health care. Medicare for all brings equity to the system through universal coverage and the elimination of medical bankruptcy. Yet the process of unwinding our current system would be painful — higher taxes, longer wait times for health care, and job losses.

Health care reform is more complicated than questions of right or privilege. As we think through our options — whether it’s Sanders’ bill, the seven alternatives that fall under the Medicare for all banner while proposing different approaches to coverage or prices, or smaller adjustments to our current system — we must ask tough questions about the trade-offs we are willing to accept and the impact such a revolutionary change would have on everyone in the health care system — patients, providers, and payers.

Andrew Schuette is an audiologist at Washington University School of Medicine who will join Barnes-Jewish Hospital as an administrative fellow after graduating from Washington University’s Olin Business School this spring. Peter Boumgarden, Ph.D., is professor of practice of strategy and organization at Washington University’s Olin Business School.

  • Am I supposed to care about 45,000 people who died who were mandated to purchase health insurance but opted to pay the fine? Am I supposed to care that nearly half of Americans spend every dime they have and only have $400 in savings? We’re not just talking about the so-called “poor” here (remember: no one ever asks the question about why someone is poor. Is it because of lack of wanting to work? Much of poverty is avoidable. After all, wouldn’t we all be poor if we decided to skate through life?). In many cases, we’re talking about people who can afford to purchase insurance and save money but have f’d up priorities. I don’t believe that half of Americans can’t afford to save money. I’ll bet they all have iPhones with $100+ monthly phone plans and other unnecessary things. Don’t ruin my healthcare options because of morons.

  • Agree about tradeoffs. One reform that would likely be needed is to have cheap or free medical school (in addition to free college) once Medicare-for-All is enacted. Yep we can’t let physicians graduate in huge debt and have that work well with this . . .

    Sanders has been very aware that the reduction of jobs in the medical sector with so much less administration needed (if MfA is done in a uniform, sensible way) will unemploy people and that that too needs factoring in (I’m one of those who would be unemployed myself).

  • I have been a Democrat all of my life. However, I do not support Medicare for all and will vote against any nominee who runs on that platform. I will support a Democrat who runs on trying to fix the ACA. Bernie Sanders could not stand the thought of allowing Barack Obama getting credit for trying to fix the healthcare problem in this country. There is no reason at all that people who can afford to pay for their health insurance should get it for free. Working people with good salaries should pay something based upon their ability to pay. We need the government to look at drug prices and how the American people are being cheated by the pharmaceutical companies.
    The followers of Bernie Sanders are going to ruin this country.
    Thank goodness we have Howard Schultz running for president. He is a man with common sense.
    I can see many people leaving the Democratic party because of all the Sanders crazies running for president.

    • I will not vote for any candidate who doesn’t support Medicare For All. Insurance is not healthcare! Some things should be beyond “for-profit.” The only profit in caring for the sick is to bleed them to death (figuratively). I see it every day as the parent of a child with a life-threatening, pre-existing condition. My child should not be the sacrificial lamb that guarantees through her suffering that greedy CEOs get their jets and vacation homes. Enough is enough!

  • Medicare for all or single payer will only be “Painful’ for the industry ghouls that are profiting from the deaths of Americans. The healthcare industry would no longer profit from misdiangosis or misleading the public. Healthcare is the only industry where they make more money being wrong. There won’t be a profit in vaccine denial and psuedo scince either.

  • Having health insurance coverage is not an outcome in any sense and the assumption that people who are uninsured want insurance and view it as a good thing is nothing more than an assumption. For example, I do not have flood insurance. If a vote is proposed for universal flood coverage, I would vote against it as I would not want anyone to have to pay for my flood insurance.
    The argument that it is empathetic to want everyone to be insured is not a good one either since those in the U.S. who pose a need have the option of Medicaid. You will also notice that politicians who are for universal health insurance call it “Medicare for all” instead of the more apt “Medicaid for all”.

    • ” I do not have flood insurance. ”
      this analogy is off-base I think. of course universal flood insurance would not make sense for everyone; not everyone lives in flood-y areas, among other reasons. but health is something that EVERY SINGLE LIVING PERSON will absolutely and intimately be affected by in their life. furthermore, if everything you care about is destroyed in a flood, at least you survived. on the other hand, if your health is destroyed by any number of things.. you’re dead. if you don’t have good health and you get caught in a flood, you might end up dead too.

      the point is, in a decent society that claims everyone has equal opportunity, the most basic necessity of a decent life — one’s health — should be taken care of.
      ” those in the U.S. who pose a need have the option of Medicaid. ” uh.. what about those many many people who don’t qualify for medicaid but still don’t make enough to afford basic health visits, not to mention weathering emergencies without losing a giant fraction of their finances or even just going bankrupt..

      not to even mention that the prices of so many things are so effin outrageous thanks to the essentially unchecked medical/pharmaceutical and insurance industries that jack up all the costs and profiteer off people’s sickness??

      how much people are already spending on medical costs is -INSANE- and it’s been demonstrated that a medicare-for-all system would save money for the public on the whole
      not to even even mention how much money and money on top of money keeps being budgeted to the military, to obscenely rich people in the form of tax cuts ..

  • The Disabled for 22 years plus had a job before disability and did not buy an insurance policy I wonder how he survived for 22 years ? Free M edicare for all would Bankrupt the U S A Economy. Who benifits? THE LAZY NONWORKING WHO WILL NOT EVEN MAKE AN ATTEMPT TO GET A JOB . EMPLOYMENT IS UP AND COMPANIES ARE HIRING BUT THEY WILL NOT LOOK FOR A JOB. I HAVE PHISACALY TOTALY DISABLED AND IN GREAT PAIN FOR 18 yrs and I pay for Medicare why should the lazy nonworkers get it Fee?

    • A dumb fix everyone would then drop there policies and Doctors would not treat. What about stopping the free illegal aliens benifites????

  • Skewed analysis, W. Germany did not ask how much it will cost to integrate E. Germany. It’s about the idea of ‘citizenship’ — that includes ‘trade offs’ as well as the rights, privileges. Trade-off: your parent/sister/son v. other’s?

    • Good point Kerim… though I would say considering trade-offs doesn’t mean you don’t take them. For all of us, the challenge is expanding our sense of empathy beyond whose viewpoint we normally consider. As someone with insurance, that is always the uninsured. But, for example, as a non-physician, I often fail to consider the take of those who exist directly within the system. We may not weight that as highly, but still worth noting in the decision-process.

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