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How the Bernie Sanders Plan Would Both Beef Up and Slim Down Medicare

Mr. Sanders says that the transition to the Medicare program would achieve several goals: It would ensure universal coverage, it would improve the affordability of health care for many Americans and it would save the country money.

Whether it can achieve that third goal depends a great deal on how the new Medicare-for-all system would be managed, and the Sanders plan leaves a lot of those details unclear for now. Covering everyone would not, by itself, make the health care system in the United States as inexpensive as those of other nations with universal health care systems. That sort of cost control would require its own set of policies and difficult choices.


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Bernie Sanders greeting supporters after a rally on behalf of the Affordable Care Act in Convington, Ky., in July.

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Jay Laprete/Agence France-Presse — Getty Images

In his news conference introducing the bill on Wednesday, Mr. Sanders focused his ire on insurance and drug companies, two profitable sectors of the health care system. But insurance and drug company profits don’t make up the bulk of America’s health care spending. Single-payer advocates argue that the simplicity of a single, government payer would reduce paperwork and office staff, and that is almost certainly true. But most spending in the health care system is on medical care from doctors and hospitals — and squeezing savings there may be harder.

To get savings from those areas might require reducing doctors’ pay or hospitals’ numbers of medical professionals. It could require eliminating some medical treatments that are currently offered. Even cutting spending on pharmaceuticals would have ripple effects, potentially limiting access to new or expensive treatments, or reducing investment in new technologies.

The bill specifies that Medicare would be run with an annual budget, leaving government officials to decide how to make the country’s medical spending conform to such totals every year. It also says that the government should evaluate the effectiveness of different medical treatments. Such a system has precedent: Several countries, including Canada and Britain, establish health care budgets that must be met and assess the value of medical services to determine what should be covered.

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But such budgets and limits have been politically toxic in the United States, where politicians have been reluctant to say that the government should restrict care. The Affordable Care Act established a theoretical limit on spending per Medicare beneficiary, establishing a board that would reduce costs if a cap were met. But that board, assailed as a “death panel,” has never been called upon to make such choices, for no members have ever been nominated to it.

Mr. Sanders sells the bill as a broad expansion of care, by ensuring that all Americans have similar, broad benefits and little financial exposure to medical bills. At Wednesday’s event, he stood flanked by several prominent Democratic cosponsors and medical providers who offered testimonials about how a Medicare-for-all plan would improve access to needed health care.

The plan increases the generosity of Medicare substantially. It adds coverage for dentistry, optometry and audiology care, not part of the traditional program. It also eliminates premiums, deductibles and most co-payments for medical care, which are significant costs for many people.

The size of the Medicare budget is also unspecified. In part, that’s because the Sanders bill does not establish a funding mechanism for its planned overhauls. In a separate white paper, Mr. Sanders’s office spells out some possible revenue sources, including increases to payroll taxes, and to high-end income taxes and some corporate taxes. But those funding streams, politically risky in their own right, would need to be debated and measured before the realistic scale of the Medicare-for-all budget would be clear.

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This different Medicare would face the push and pull of expanded reach and fixed means: one that would tend to increase the cost to the government for care, and one devised to reduce it. Just what sort of Medicare program results would depend on the government that runs it.

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