“What if my job doesn’t exist anymore?” she asked in a recent interview.

TOP: Deanna Mazur, a health care billing manager in Pittsburgh, wonders if her job might disappear if the country adopts a Medicare for All-style health care system. BOTTOM: The University of Pittsburgh Medical Center, one of two hospital systems that dominate the local economy. Once the headquarters of the U.S. steel industry, the city’s largest industry is now health care. | Scott Goldsmith for Politico Magazine

This question has particular resonance in this part of Pennsylvania, a must-win swing state in the presidential race, which has already seen massive job dislocation from the decline of manufacturing. As Pittsburgh’s iconic steel industry has been gutted, the city’s economy has been hugely buoyed by health care, which has grown into the region’s largest industry — employing about 140,000 people, or 20 percent of the regional workforce. The city’s former U.S. Steel complex is now, appropriately enough, the headquarters of a mammoth hospital system, one of two health care companies deeply entrenched in the city’s economy.

There are lots of health reform ideas that wrap themselves in the “Medicare for All” label, ranging from a single government-run system to plans that maintain a role for private insurance companies. But under the most ambitious schemes, millions of health care workers would be at least displaced if not laid off, as the insurance industry disappears or is restructured and policymakers work to bring down the costs of the system by reducing high overhead and labor costs. The reform proposals being promoted by Democratic presidential candidates have barely grappled with this problem.

Initial research from University of Massachusetts economists who have consulted with multiple 2020 campaigns has estimated that 1.8 million health care jobs nationwide would no longer be needed if Medicare for All became law, upending health insurance companies and thousands of middle class workers whose jobs largely deal with them, including insurance brokers, medical billing workers and other administrative employees. One widely cited study published in the New England Journal of Medicine estimated that administration accounted for nearly a third of the U.S.’ health care expenses.

Even if a bigger government expansion into health care left doctors, nurses, and other medical professionals’ jobs intact, it would still cause a restructuring of a sprawling system that employs millions of middle-class Americans.

Claire Cohen, a Pittsburgh-based child psychiatrist, voted for Bernie Sanders, the architect of the most sweeping version of Medicare for All, in the 2016 Democratic presidential primary. She says the national discussion about single payer and its overwhelming focus on paying higher taxes or losing private insurance misses the point ― she argues individuals would see greater benefit from a health care system without premiums, copays and other costs that increasingly make health care out of reach. But the question about jobs, she says, is a “legitimate” issue ― one she says people haven’t completely thought through.

“You don’t want to leave all these people in the lurch without jobs,” Cohen said.

Having it both ways

The idea of one national health plan covering all Americans has steadily grown more popular in public opinion polls over time, a sea change that coincides with Medicare for All becoming near orthodoxy for progressive Democrats. Prior to 2016, when Sanders made it the linchpin of his insurgent run for president, less than half of Americans supported setting up a such a system, according to Kaiser Family Foundation polling. Now, just over half of the public backs it.

Claire Cohen, a child psychiatrist in Pittsburgh, supports the idea of Medicare for All but calls the question of how many workers might lose their jobs a “legitimate” issue. | Scott Goldsmith for Politico Magazine

When it comes to the costs of reform, taxes are the headline issue, and the movement’s advocates on the national stage ― Sanders and fellow Democratic presidential contender Elizabeth Warren, among others ― have largely had to defend Medicare for All against charges that middle-class taxes would have to go up to finance a new government-run system. But the question of what single-payer health care would do to jobs and the economy has largely been overlooked. In the past, Sanders has answered questions about the economic ramifications with vague claims about transitioning to other jobs in the health sector.

“When we provide insurance to 29 million people who today don't have it, when we deal with the problems of high deductibles and copayments and more people get the health care that they want and they need, weʼre going to have all kinds of jobs opened up in health care,” Sanders claimed during a 2016 CNN town hall when asked by a retired health insurance worker what would happen to jobs in the industry. “And the first people in line should be those people who are currently in the private health insurance industry.”

Economists dispute the extent to which this would occur. Robert Pollin, co-director of the Political Economy Research Institute at the University of Massachusetts-Amherst who has consulted with Sanders’ and Warren’s teams over Medicare for All, says that while people could be retrained for different jobs, there are no guarantees they’d work in the newly created government health care system, since one of the goals is to cut down on administrative overhead. “You can’t have it both ways. You can’t have savings through administrative simplicity and more jobs. The government won’t need these people,” Pollin said.

Health care workers are interwoven throughout the economy, employed by large institutions like hospitals, health insurance companies and nursing homes but also in places like small accounting firms that help clinicians get reimbursed for care, and as independent brokers who help sell insurance products to customers.

Mazur handles medical billing for physicians through Medicare, Medicaid and private insurance, the last of which is the most complicated. Under Medicare for All, “They don’t have to worry about, am I going to get paid for this service based on what insurance the patient has? It would be the same rules for everybody.”

In Pittsburgh, workers in the health care economy interviewed for this article weren’t necessarily against a single-payer system, even if it meant their work would be personally affected. But they did consistently say that Democratic candidates for president need to make the employment implications clearer.

Marc Schermer, a Pittsburgh-based insurance broker who sells health plans to individual customers as well as small businesses, says he’d likely experience a temporary setback but believes he’d manage since he sells other kinds of insurance, too. He even thinks single payer is an idea “he could get behind” because removing private insurance companies from the system would simplify things.

“I’m pretty well diversified so that if suddenly the ‘Medicare for All’ thing happened, and companies like United and Highmark and UPMC and Aetna were brushed aside, I would still have something to do,” Schermer said. “But there are a lot of people who are employed directly by those companies who would be up a creek.”