Medicare for All

Right now there are a bunch of competing proposals for how to create a universal healthcare system for the USA. People are starting to talk about which 2020 candidates support which schemes, and who to support in the Democratic primaries based on that information. In particular, Beto O’Rourke has been criticized for not backing Medicare for All, and instead backing a scheme called Medicare for America.

Based on my experience of UK public and private healthcare, and US HMOs and other health insurance, I have some strong opinions about what a good healthcare system should look like.

Let’s start with the goals. The overall aim is to make sure that nobody suffers because they can’t get essential medical treatment. A supplementary goal is to reduce the per-capita cost of healthcare, because the US spends far more than any other country for results which aren’t as good as many.

Here are a couple of things which are not goals, or at least should not be goals in my view:

  • Eliminating insurance companies
  • Allowing government to dictate drug prices (that’s a whole separate issue)

So, let’s consider the differences between the different Democrats’ proposals, and how they support the goals.


Clearly everyone should be eligible for treatment. By everyone, I mean everyone who is a taxpayer or child of a taxpayer, and hence paying into the system. Notice I say “taxpayer” and not “citizen”.


All medically necessary treatments should be covered. What’s medically necessary? Personally, I am happy to see a panel of expert doctors decide that.

Currently, what’s covered in US healthcare is mostly decided by corporate accountants, which is not reasonable, as trying to run healthcare as a profit-making business is the cause of the mess we’re in at the moment.

Coverage should include vision and dental treatment. Many people don’t realize how important dental treatment can be. It’s not about having perfect teeth — untreated dental issues can turn into chronic meningitis and antibiotic-resistant fevers.

What about private insurance?

Private insurance should continue to be available, as it is in the UK. I see no benefit to trying to eliminate private insurance. If you’ve got the money and want to spend it on better healthcare, go ahead!

The goal here is to make sure everyone has essential healthcare. Eliminating the insurance industry is not a goal, no matter how much we may hate them. If state-run healthcare works well, the insurance industry will naturally shrink due to market forces.

Remember the fuss made over the affordable care act and “If you like your current insurance plan you can keep it”. Let’s not step on that rake again. Let’s not mess with what insurers can do at all. Don’t mandate that they offer anything, let them exclude people as they wish, just provide a universal healthcare system for those who can’t or won’t participate in insurance provider schemes.


Who pays?

Every taxpayer pays. Yes, even if you have opted to pay insurance for different or additional healthcare options, you still have to pay taxes to fund the base universal healthcare system. Just like I still have to pay taxes to fund schools even though I don’t have kids, and still have to pay fees to help pay for rural phone service even though I opted to get rid of my phone line and have a mobile phone and fiber Internet.

Whether you call the payment into the system a tax or a premium is of no interest to me, as long as it’s universal.

Cost-sharing features

Co-pays suck. My employer’s insurance has $0 co-pays for routine checkups, and there’s a very good reason for that: if you have a co-pay, it discourages people from going to the doctor. That means trivial problems become more serious, and more expensive to treat.

The counter-argument is that there are time-wasters who turn up with imaginary problems. Well, OK, maybe flag those people in the system and start charging after the Nth visit in any given month? But for the rest of us, no co-pays. Believe me, I’m not going to casually spend half my day in the doctor’s office unless I have a compelling reason to be there.

Deductibles suck too, for much the same reason. Last year my wife had some troubling symptoms, and a doctor suggested that it would be a good idea to go to urgent care and get an ECG test. Because of deductibles, that was going to cost over $1,000. I imagine many people would say hey, I’ll wait and see if it gets worse. After all, most Americans — even the ones with jobs and medical insurance — are living paycheck to paycheck. In one study, only 35% felt certain they could come up with $2,000 for a sudden need.

So, definitely no deductibles, and no co-pays.


  • “Medicare for All” is a terrible proposal, because it seeks to eliminate private medical insurance. That will be politically unacceptable, as it goes further than most European nations towards a Communist model in which inequality is eliminated. (And I hate to use the ‘C’ word, but it fits.)

  • “Medicare buy-in” is a terrible proposal, because it has deductibles and co-pays.

  • “Medicaid buy-in” is OK, but it allows states to set premiums, and you just know that Republican states will attempt to sabotage the system by abusively adjusting premiums or refusing to collect them. Also, I see mention of out-of-pocket costs.

  • “Medicare for America” is terrible, because it has deductibles and co-pays.

  • Government-run options, in which government sets up a public insurance plan that competes with the exchanges, are all bad because they all keep the insurance bureaucracy in place. That means no cost savings, and the same frustrations everyone suffers with current insurers.

So depressingly, none of the proposals are actually good ones. Beto’s favored option is bad, but not because it allows insurance to continue; it’s bad because of the co-pays and deductibles.

If I had to pick the least bad, I think I’d go for “Medicaid buy-in”, because Medicaid co-pays are at least a known quantity and set low. But surprisingly, Bernie doesn’t seem to like that suggestion.

I predict it’s going to feel like a long primary season.