5 Things the 2020 Democrats Aren’t Telling You About Medicare for All

The 2020 Democratic presidential primary has been dominated by health care -- in particular, a debate over the costs and benefits of abolishing private insurance and moving to a universal single-payer system like “Medicare for All.” But there are several real-life hurdles to creating that kind of health care system that are getting far less discussion.

Here are five things you’re not hearing on the campaign trail or the debate stage about the real prospects of Medicare for All:

1. It doesn’t matter who gets elected president: If Congress doesn’t support it, it can't become law.

The candidates’ intricate debates over health policy might lead you to believe the next president gets to wave a wand and transform the system, but not even close: There is only so much even the most active president can do to set health policy, as President Trump’s stymied efforts to abolish the Affordable Care Act have proven. Almost all major changes must run through Congress. And while Democrats control the House and are likely to retain it in 2021, Medicare for All has far fewer supporters there than it needs to pass. The Senate is an even heavier lift. Even if Democrats win a majority next year – a big if – most Senate Democrats and most Democratic candidates running to unseat Republican incumbents are either skeptical of or hostile to the single-player plan.

Even if the next president moves to abolish the legislative filibuster – as several 2020 candidates have suggested – Medicare for All doesn’t have 50 Senate votes, let alone 60. This is why Bernie Sanders and outside groups stumping for single payer have stressed the need to go beyond winning elections and build a national grassroots movement to pressure a reluctant Congress to get on board.

2. The health care industry doesn't just oppose Medicare for All — it opposes every plan that would expand the government’s role in health care.

In the Democratic argument over health reform, the Warren/Sanders wing tends to come under attack from moderates with some version of “It’s not realistic and can never pass,” usually nodding to formidable opposition from the hospital, insurance and pharmaceutical industries.

It’s not clear, however, that the moderates’ plans would fare much better. The same industries are equally set against their more incremental health care reforms. The main industry group fighting these proposals has used the word “disastrous” in reference to the relatively modest proposals of Joe Biden and Pete Buttigieg. And anyone who thinks that kind of comment is just saber-rattling should recall what happened last summer, when the industries successfully mobilized to kill congressional action on surprise medical bills – a fairly narrow health care problem with rare bipartisan agreement.

This has led Medicare for All supporters to cite the industry’s intransigence as a point in their favor: If insurers and providers will fight even modest efforts to bring down health costs, they argue, why not push for the boldest measure possible?

3. The courts could kill Obamacare in 2020, and that could doom Medicare for All.

Federal courts could rule any day now on a case brought by red state attorneys general and backed by the Trump administration that threatens to strike down either the entire Affordable Care Act or its protections for people with preexisting conditions. Either outcome (assuming it’s upheld by the Supreme Court) would throw the nation’s health care system into chaos. Tens of millions of people could lose their private insurance. Many more could be subject to premium hikes based on their gender, age or health status. Programs aimed at helping seniors afford prescription drugs would be wiped out. Access to free birth control and mammograms could disappear.

A new president inheriting this crisis in 2021 would be consumed with stabilizing the nation’s health system and making sure millions of newly vulnerable patients aren’t kicked off their insurance, eating up the energy and political capital required to push for a transition to Medicare for All. If supporters think they could take advantage of this turmoil to push single-payer reform through, they have yet to make that case.

4. Even if Medicare for All survives court challenges, it could still end up weakened by lawsuits.

Nearly a decade after the passage of the Affordable Care Act, court battles continue to rage, threatening to chip away at particular provisions or eradicate the system in its entirety. The same would be true, legal experts tell POLITICO, of Medicare for All. Even though the federal government’s constitutional right to regulate private insurers and health care providers has been firmly established for decades, that wouldn’t stop the forces who would seek to undermine a single-payer health system.

“There could be a death by a thousand lawsuits approach,” says Katie Keith, a law professor and researcher with Georgetown University’s Center on Health Insurance Reforms.

Other legal experts warn that doctors and hospitals could get creative in trying to circumvent Medicare for All and continue taking private payments – and could challenge in court the exact definition of “insurance.”

5. No country on earth, no matter how socialist, has been able to make Bernie Sanders' vision work.

In defending Medicare for All on the campaign trail, Sanders, Elizabeth Warren and their allies frequently point to the many other developed countries that have successfully implemented a universal health care regime. But Sanders’ bill -- which makes every health service available to every U.S. resident free of charge -- would create a system more generous and far-reaching than any other country in the world. Its ban on nearly all forms of private health insurance other than for niche procedures like cosmetic surgery is also unlike anywhere else on earth.

Denmark, the United Kingdom and Germany, for example, all charge patients for some pharmaceuticals and hospital stays. Australia charges copays for visits to a specialist. In the Netherlands, residents have to pay down a nearly $500 deductible before their insurance kicks in. In Canada, the country Sanders points to most frequently as a model, supplemental private insurance is widely used to cover things not covered by the government, including mental health, vision, dental care and many prescription drugs.

Every country with some form of universal health care either requires some out-of-pocket costs or puts a limit on the benefits available in order to make the system work. And many, if not most of them, still have thriving parallel private insurance industries.