How This Compares to Medicare for All

This is a beta. We are publishing it early, unfinished, and open to being wrong, because we would rather be corrected now than after it is printed. Household dollar figures are illustrative until our calculator is live; cost estimates are ranges, and we say so. If you think a number here is wrong, or a piece of the design would fail in practice, tell us. That is what this draft is for.

Medicare for All was never wrong. It is half a plan.

It is a well-drafted, comprehensive bill about who pays. It contains almost nothing about whether the care exists to be paid for. This plan keeps most of it and adds the missing half. The right position is "Medicare for All, plus the plan to actually build the care," not a rival product.

What we keep, unchanged

• Single public payer. Everyone covered from birth, automatically, with one card that works everywhere.
• A genuinely comprehensive benefit package: hospital, ambulatory, primary and preventive, drugs, mental health and addiction, labs, maternity, pediatrics, dental, vision and hearing, rehabilitation, emergency. Better specified than most single-payer proposals anywhere, and we should not try to improve it.
• Zero cost-sharing. Defensible on the evidence and administratively cheaper than collecting.
• Global budgets for institutions, negotiated fee schedules for individual providers. The correct payment architecture, and the part most of its critics have never read.
• Drug price negotiation with a compulsory-licensing backstop. We extend it rather than replace it.
• And the bill itself. Medicare for All is drafted legislation with the conforming amendments to ERISA and the tax code. Turning our plan into a bill means starting from that text, not from a blank page.

Where we differ, and why

	Medicare for All	This plan
Supply	Almost nothing — a small workforce title	The centerpiece: capacity, doctors, nurses, facilities. This is the whole reframe
What you get first	Nothing until your cohort's enrollment date	Debt canceled on day one; denial reform by month three; free chronic drugs by month six; out-of-pocket capped by month 12 — none of it requiring enrollment in anything
Medical debt	Not addressed	Canceled — and the people who already paid theirs off are refunded
Premiums during transition	Unregulated until your cohort enrolls	May never rise, must fall every year, backed by federal reinsurance
Ownership	Not addressed	Providers stay private, but no profit distribution, mandatory participation, active anti-consolidation
Long-term care	Home and community care; institutional care left with Medicaid	Full benefit, both settings — the split reproduces exactly the gap families fall into today
The insurers themselves	Wound down; vertical integration not addressed	Split four ways. The 2019 bill predates the insurers buying the providers. UnitedHealth now employs or contracts roughly one in 10 American doctors
Worker transition	About 1% of budget	A funded title — wage replacement, retraining, first claim on the largest health hiring in American history
Private insurance	Bans duplicative coverage	Permits supplementary coverage for what the schedule excludes. Canada's ban is the origin of its 40-year wait-times politics
Benefits definition	"Medically necessary," left to the Secretary	A published schedule from an open, independent body — put the rationing decision in daylight where it can be defended
Friction	Not addressed	One federal prior-authorization portal answering in 60 seconds; care provided during appeals; a national appointment search

Where their approach is arguably better

These are the places we may be wrong.

Simplicity. "Medicare for All" fits on a sign. "Medicare for All plus a national capacity program plus ownership conditions plus a prize fund" does not. Every addition is a surface a hostile campaign can attack. There is a real argument for a plan with one idea in it.

The private insurance ban. Our supplementary-insurance valve is more politically survivable, but their ban is more equitable, and the two-tier drift it prevents is real. We have chosen the politics over the equity here. That is the trade.

The argument in one move

The ACA insured around 20 million people. Rural hospitals kept closing, maternity wards kept closing, and waits got longer. A demand-side bill in a supply-constrained market raises prices and queues.

Medicare for All is a much bigger demand-side bill. Pass it on its own into a country with 2.7 hospital beds per thousand people and a shortfall of roughly 370,000 physicians, and the first thing 30 million newly covered Americans would discover is that they still cannot get an appointment. The system would be judged a failure in its first 18 months, by the very people it had just covered.

That is not an argument against Medicare for All. It is an argument that it was never enough on its own, and that the missing half is the half that takes 10 years, which is why it has to start first.