Medicare For All Is A Brand, Not A Plan

What traditional Medicare actually delivers

Start with the thing most people outside the program don’t know: traditional Medicare is not free, and for many seniors it is not affordable.

You pay in through every paycheck for decades. Then you turn 65 and find a Part B premium, a separate Part D premium, no annual cap on out-of-pocket spending, and one real way to protect yourself against that exposure — a Medigap policy from a private insurer, at a third premium. Stack them against a median older-adult income in the low fifty thousands and the arithmetic is unforgiving.

Traditional Medicare offers broad access to doctors and hospitals. Broad access is not affordable access. A benefit you cannot afford to use is an incomplete form of protection, and a program built to provide security in old age has drifted a long way from that purpose while everyone kept applauding the founding.

Then there is what it refuses to cover. Routine dental care. Hearing aids and meaningful audiology. Routine vision. We file these under “supplemental,” as though they were spa benefits.

They are not. Untreated hearing loss is associated with isolation, depression, falls, and cognitive decline — and hearing aids run into the thousands of dollars, which puts them out of reach for the woman on a fixed income who then stops calling her daughter because the phone has become difficult. Untreated dental disease drives infection, malnutrition, and avoidable hospitalization; a person who cannot chew does not eat well, and a person who does not eat well does not heal.

Medicare pays generously for the downstream consequences of these conditions and declines to cover the services that would have prevented them. That is not fiscal discipline. It is a fragmented conception of health that medicine abandoned decades ago.

And notice why the gaps persist: benefit design belongs to Congress. Modernizing the program requires legislation, in an era when even popular healthcare changes are hard to pass. A universal system cannot stay current with medicine if updating its basic benefits takes a decade-long political campaign.

The price list is upside down

The deepest flaw gets the least airtime.

Medicare does not merely pay for care. It sets the relative value of care across the country, and because commercial insurers benchmark to it, Medicare’s judgments propagate through the entire system. That fee schedule is the most consequential document in American medicine.

It pays well for doing things to people. It pays poorly for thinking about them. A procedure is compensated handsomely. The twenty-minute conversation about whether that procedure serves a frail 84-year-old is not.

The consequences aren’t mysterious. Health systems build what generates revenue. Physicians choose specialties with the fee schedule in view. Medical students read the price list, and they are not irrational. We end up with abundant procedural capacity and a primary care, geriatrics, and behavioral health workforce we cannot recruit or retain.

Fee-for-service completes the circuit: the system earns when patients are sick and earns more when more is done. Volume is the business model; prevention is a cost center. We have spent fifteen years bolting value-based payment onto this chassis, and the chassis keeps winning.

So when someone proposes extending this program to everyone, I want to know which part they’re extending. The coverage guarantee, or the payment architecture that produced the delivery system we’re now trying to repair? Rhetoric does not separate them.

Medicare Advantage is not the answer either

I run a Medicare Advantage plan. Discount me accordingly — and discount the nostalgia too.

MA answers some of this. It caps out-of-pocket costs. It covers dental, vision and hearing. It pays for transportation, food and in-home support. Capitation at least points the money toward keeping people well. Lower-income beneficiaries choose it in large numbers not because they misunderstand traditional Medicare but because they understand it precisely.

And my industry has spent two decades earning its critics.

Risk adjustment was built to pay appropriately for sicker members. It became an engine for documenting diagnoses, and across this industry coding drifted into an end in itself, detached from whether anyone treated the condition. Plans compete on supplemental benefits, some genuinely valuable and some shiny objects — cards and allowances designed to win an enrollment season rather than to matter at three in the morning in an emergency department. Prior authorization, applied at scale, stops being a check on waste and becomes a tax on care, falling hardest on the patients least able to appeal. And Star Ratings have become a scoreboard rather than a signal: what good does it do a senior to have her call answered on the first ring if her plan then drags its feet approving cancer treatment? When ratings slip, this industry’s reflex is increasingly to sue CMS rather than to ask what the ratings revealed.

I’ve argued for specific repairs — standardizing the benefit package the way Ron Wyden and his colleagues standardized Medigap thirty-five years ago, so plans compete on outcomes instead of on the season’s most eye-catching perk; rebuilding quality measurement around the moments that determine an older person’s trajectory, the first fall, the new diagnosis, the transition to hospice; fixing risk adjustment so it pays for caring for sick people rather than describing them; constraining prior authorization; and ending annual enrollment, because a plan working on a twelve-month horizon cannot rationally invest in a five-year outcome. Most of that would cost my industry money. Some would cost my own company competitive room I currently enjoy.

I’d take the trade.

MA is useful evidence in this debate, but not as a ready alternative. It proves the benefits traditional Medicare withholds can in fact be delivered. It also proves how fast a public program run through private hands generates gaming, bureaucracy and mistrust when oversight is thin and incentives are careless.

Neither program should be romanticized or demonized. Both should be studied.

Say what you actually mean

Here is what I’d ask of this movement, in good faith, because I think we want the same destination.

Some of you already do this work. El-Sayed’s platform says plainly that he would cover vision, dental and hearing and eliminate premiums, copays and deductibles. That is a serious answer — and it is also an admission. He is not campaigning on Medicare. He is campaigning on a program that would have to be built.

So build it in public. Does the system keep fee-for-service, and if so, what stops the overutilization and the starvation of primary care? If it moves to global budgets or capitation, who carries the risk, and what keeps risk-bearing from becoming denial? How are prices set, and how do those prices avoid reproducing the procedural bias already deforming American medicine? How does the benefit package evolve without an act of Congress each decade? How do you tell legitimate utilization management from obstruction — a question my own industry has answered badly, and one that does not disappear when the payer is the government?

And say how it is financed. Not by comparing new taxes to today’s premiums, which is the easy version, but by accounting for employer contributions, household spending, existing subsidies, changes in provider payment, administrative costs, and who ends up bearing what.

None of these are objections to universal coverage. They are what taking it seriously looks like.

The moral claim underneath Medicare for All is correct. Nobody should skip care they cannot afford. No family should be bankrupted by illness. No one should lose coverage with a job.

But moral clarity about the destination has become a substitute for precision about the vehicle, and that substitution is its own kind of evasion. Invoking a beloved program is easier than examining it. It feels like conviction while asking nothing of us.

Universal coverage deserves more than a slogan. It deserves a blueprint.