My daddy’s heart attack nearly sent our family skidding over a financial cliff. Today I think about all the kids this year who will face the double blow of nearly losing a parent and then watching their lives turn upside down as their families struggle to pay a growing stack of medical bills.

I spent my career studying why so many hard-working middle class families were going broke. For years, my research partners and I traveled the country from bankruptcy courtroom to bankruptcy courtroom, talking directly to people who’d seen their lives turned upside down. We interviewed lawyers, judges, and families involved in bankruptcy cases. To save on printing costs, we lugged around a Xerox machine (I nicknamed him “R2-D2”) to save money on photocopying court records.

Eventually, we built the largest and most comprehensive database of consumer bankruptcy data ever assembled. That first study surprised us: we found that 90% of families went bankrupt because of job loss, medical problems, and marital disruption. That finding was confirmed in 2007 by my later research, which found that the number one reason families were going broke was health care — and three quarters of those who declared bankruptcy after an illness were people who already had health insurance.

It’s been nearly thirty years since we published that first groundbreaking study. And after all that time, here’s where we are: between 2013 and 2016, the number one reason families went broke was still because of health care — even though 91.2% of Americans had health insurance in 2016.

Families are getting crushed by health costs. Just look at the numbers.

$12,378. That’s how much an average family of four with employer-sponsored insurance personally spent per year on employee premium contributions and out-of-pocket costs in 2018. And this figure has increased each year.

87 million. That’s how many American adults in 2018 were uninsured or “underinsured” — meaning either they have no insurance or their so-called health insurance is like a car with the engine missing. It looks fine sitting on the lot, but it is inadequate if they actually need to use it. Nearly one in every two adults not currently on Medicare has no insurance or unreliable insurance.

37 million American adults didn’t fill a prescription last year because of costs. 36 million people skipped a recommended test, treatment, or follow-up because of costs. 40 million people didn’t go to a doctor to check out a health problem because of costs. 57 million people had trouble covering their medical bills.

Today, in 2019, in the United States of America, the wealthiest nation in the history of the world, inadequate health coverage is crushing the finances and ruining the lives of tens of millions of American families.

I’m running for President based on a radical idea — calling out what’s broken and speaking plainly about how to fix it.

All my plans start with our shared values. There are two absolute non-negotiables when it comes to health care:

One: No American should ever, ever die or go bankrupt because of health care costs. No more GoFundMe campaigns to pay for care. No more rationing insulin. No more choosing between medicine and groceries.

Two: Every American should be able to see the doctors they need and get their recommended treatments, without having to figure out who is in-network. No for-profit insurance company should be able to stop anyone from seeing the expert or getting the treatment they need.

Health care is a human right, and we need a system that reflects our values. That system is Medicare for All.

Let’s be clear: America’s medical professionals are among the best in the world. Health care in America is world-class. Medicare for All isn’t about changing any of that.

It’s about fixing what is broken — how we pay for that care.

And when it comes to health care, what’s broken is obvious. A fractured system that allows private interests to profiteer off the health crises of the American people. A system that crushes our families with costs they can’t possibly bear, forcing tens of millions to go without coverage or to choose between basic necessities like food, rent, and health — or bankruptcy.

We must fix this system. And over the long-term, the best way to achieve that goal is to move from the system we have now to a system of Medicare for All.

Medicare for All is about where doctors, hospitals, and care providers send the bill — to a collection of private insurance companies who make billions off denying people care or to the Medicare program for fair compensation. Under Medicare for All, everyone gets the care they need, when they need it, and nobody goes broke.

A key step in winning the public debate over Medicare for All will be explaining what this plan costs — and how to pay for it. This task is made a hundred times harder by powerful health insurance and drug companies that make billions of dollars off the current bloated, inadequate system — and would be perfectly happy to leave things exactly the way they are.

In 2017 alone, health industry players whose profiteering would end under Medicare for All unleashed more than 2,500 lobbyists on Washington. These industries will spend freely on shady TV ads and lobbying to convince people that a program that saves them massive sums of money will somehow cost them money. That being able to see the doctors and get the treatments they need regardless of what their employer or their insurance company thinks is somehow actually a loss of choice. That a program that covers more services, more people, and costs the American people less than what we currently spend on health care is somehow too expensive.

Meanwhile, where are the 2,500 lobbyists for the people who get sick and can’t pay their medical bills? Where are the hundreds of millions being spent so that people who are trying to balance a budget around rising health care premiums and growing deductibles and copays can make their voices heard in Washington? Washington hears plenty from the giant health insurance and giant drug industries, but not so much from families being squeezed to the breaking point.

So let’s focus on families’ expenses and families’ health care.

Start with the Medicare for All Act — which I have cosponsored. The bill provides a detailed proposal for how to achieve our end goal. But as economists and advocates have noted, the legislation leaves open a number of key design decisions that will affect its overall cost, and the bill does not directly incorporate specific revenue measures. While much of this ambiguity results from the reasonable choice to delegate significant implementation discretion to the Executive Branch, it has also allowed opponents of Medicare for All to make up their own price tags and try to scare middle class families about the prospect of tax increases — despite the conclusions of expert after expert after expert that it is possible to eventually move to a Medicare for All system that gives both high quality coverage for everybody and dramatically lowers costs for middle class families.

The best way to fight misinformation is with facts. That’s why today, I’m filling in the details and releasing a plan that describes how I would implement the long-term policy prescriptions of the Medicare for All Act and how to pay for it.

Under my plan, Medicare for All will cover the full list of benefits outlined in the Medicare for All Act, including long-term care, audio, vision, dental, and mental health benefits. My plan will cover every single person in the U.S., and includes common-sense payment reforms that make Medicare for All possible without spending any more money overall than we spend now.

My plan reflects careful, detailed analyses from key national experts in health policy, tax policy, and economics. By filling in the details, we can strip away all the misleading political attacks and make plain the choice facing the American people:

Option 1: Maintain our current system, which will cost the country $52 trillion over ten years. And under that current system –

24 million people won’t have coverage, and millions can’t get long-term care.

63 million have coverage gaps or substandard coverage that could break down if they actually get sick. And millions who have health insurance will end up going broke at least in part from medical costs anyway.

Together, the American people will pay $11 trillion of that bill themselves in the form of premiums, deductibles, copays, out-of-network, and other expensive medical equipment and care they pay for out-of-pocket — all while America’s wealthiest individuals and biggest companies pay far less in taxes than in other major countries.

Option 2: Switch to my approach to Medicare for All, which would cost the country just under $52 trillion over ten years. Under this new system –

Every person in America — all 331 million people — will have full health coverage, and coverage for long-term care.

Everybody gets the doctors and the treatments they need, when they need them. No more restrictive provider networks, no more insurance companies denying coverage for prescribed treatments, and no more going broke over medical bills.

The $11 trillion in household insurance and out-of-pocket expenses projected under our current system goes right back into the pockets of America’s working people. And we make up the difference with targeted spending cuts, new taxes on giant corporations and the richest 1% of Americans, and by cracking down on tax evasion and fraud. Not one penny in middle-class tax increases.

That’s it. That’s the choice. A broken system that leaves millions behind while costs keep going up and insurance companies keep sucking billions of dollars in profits out of the system — or, for about the same amount of money, a new system that drives down overall health costs and, on average, relieves the typical middle class family of $12,400 in insurance premiums and other related health care costs.

No middle class tax increases. $11 trillion in household expenses back in the pockets of American families. That’s substantially larger than the largest tax cut in American history.

Not every candidate for president supports moving to a system of Medicare for All. Some who support Medicare for All will have different ideas about how to finance and structure it. And everybody knows that there must be a real transition. But you don’t get what you don’t fight for — and my view is clear.

Every candidate who opposes my long-term goal of Medicare for All should explain why the “choice” of private insurance plans is more important than being able to choose the doctor that’s best for you without worrying about whether they are in-network or not. Why it’s more important than being able to choose the right prescription drug for you without worrying about massive differences in copays. Why it’s more important than being able to choose to start a small business or choose the job you want without worrying about where your health care coverage will be coming from and how much it will cost.

Every candidate who opposes my long-term goal of Medicare for All should put forward their own plan to cover everyone, without costing the country anything more in health care spending, and while putting $11 trillion back in the pockets of the American people by eliminating premiums and virtually eliminating out-of-pocket costs. Or, if they are unwilling to do that, they should concede that they think it’s more important to protect the eye-popping profits of private insurers and drug companies and the immense fortunes of the top 1% and giant corporations, rather than provide transformative financial relief for hundreds of millions of American families.

And every candidate who opposes my long-term goal of Medicare for All should put forward their own plan to make sure every single person in America can get high-quality health care and won’t go broke — and fully explain how they intend to pay for it. Or, if they are unwilling to do that, concede that their half-measures will leave millions behind.

And make no mistake — any candidate who opposes my long-term goal of Medicare for All and refuses to answer these questions directly should concede that they have no real strategy for helping the American people address the crushing costs of health care in this country. We need plans, not slogans.

The Cost of Medicare for All

A serious conversation about how to pay for Medicare for All requires, first, determining how much such a system would cost.

In recent years, several economists and think tanks have attempted to estimate the cost of a single-payer system in the United States. Those estimates consider how much our nation’s health care spending will change over a ten year window, and range from a $12.5 trillion decrease to a $7 trillion increase. They also consider how much additional money the federal government would need to fund this system, and those estimates range from a low of $13.5 trillion to a high of $34 trillion over ten years.

Because nobody can actually see the future, some of this variation results from different assumptions about how parts of our health care system might work differently under Medicare for All. But most of the difference comes from policy choices. And while the Medicare for All Act is clear about some of these choices — for example, generous benefits, long-term care coverage, and virtually no out-of-pocket expenses — it is silent on a number of really important ones. How much will we pay for medical care and for prescription drugs? What do we do with the existing money that states spend on Medicaid? How aggressively will we cut administrative costs? Aggressive choices mean a lower total cost. Less aggressive choices result in a higher total cost.

Serious candidates for president should speak plainly about these issues and set out their plans for cost control — especially those who are skeptical of Medicare for All. Because whether or not we make modest or transformative changes to our health care system, cancer, diabetes, strokes, Alzheimer’s, and Parkinson’s aren’t going to simply disappear. And without leadership from the top, neither will the mushrooming cost of care in America that’s bankrupting our families.

I’ve asked top experts to consider the long-term cost of my plan to implement Medicare for All over ten years — Dr. Donald Berwick, one of the nation’s top experts in health system improvement and who ran the Medicare and Medicaid programs under President Obama; and Simon Johnson, the former Chief Economist at the International Monetary Fund and a professor at MIT. Their analysis begins with the assumptions of a recent study by the Urban Institute and then examines how that cost estimate would change as certain new key policy choices are applied. These experts conclude that my plan would slightly reduce the projected amount of money that the United States would otherwise spend on health care over the next 10 years, while covering everyone and giving them vastly better coverage.

Reducing Insurer Administrative Costs

The business model of private insurers is straightforward: pay out less for medical care than they take in as premiums. This model is located right in the center of our health care system, wasting huge amounts of time and money documenting and arguing over who is owed what. Incredibly, insurance companies spend a whopping $350 billion on administration costs annually — and then, in turn, push huge additional administrative costs onto hospitals, doctors, and millions of other health care professionals in the form of complex billing — and then, in turn, drive up costs incurred by employers as they attempt to navigate the complexity of providing their employees with insurance.

Medicare for All will save money by bringing down the staggering administrative costs for insurers in our current system. As the experts I asked to evaluate my plan noted, private insurers had administrative costs of 12% of premiums collected in 2017, while Medicare kept its administrative costs down to 2.3%. My plan will ensure that Medicare for All functions just as efficiently as traditional Medicare by setting net administrative spending at 2.3%.

Comprehensive Payment Reform

In 2016, the United States spent nearly twice as much on health care as ten high-income countries, and these costs have been steadily rising for decades, growing from 5.2% of U.S. GDP in 1963 to 17.9% in 2017. But instead of resulting in better health outcomes, Americans have the lowest life expectancy of residents in high-income countries, the highest infant mortality rate, and the highest obesity rates.

Why? As a group of health economists famously wrote, “It’s the prices, stupid.”

Studies have continued to show that it’s not how much people use the health care system, often referred to as “utilization,” but rather how much people pay that drives our high spending. Compared to other high income countries, Americans simply pay more for health care. We pay more for physicians and nurses. We pay more in administrative costs. We pay more for prescription drugs.

A heart bypass surgery that costs nearly $16,000 in the Netherlands costs an average of $75,000 in the United States. A CT scan that costs $97 in Canada costs an average of $896 here. And in the United States hospitals can charge new parents for holding their newborn after delivery.

Meanwhile, private equity firms fight bipartisan legislation in Washington that might undermine the profitability of their investments or prevent their hospitals from sending patients surprise bills. And health care CEO salaries continue to soar. Between 2005 and 2015, non-profit hospital CEO salaries increased by 93% to an average of over $3 million, and last year, 62 health care CEOs raked in a combined $1.1 billion — more than the CDC spent on chronic disease prevention.

If we expect the American people to be able to afford health care, we need to rein in these costs. Comprehensive payment reform, as part of Medicare for All, will reduce this component of health care spending. Under my approach, Medicare for All will sharply reduce administrative spending and reimburse physicians and other non-hospital providers at current Medicare rates. My plan will also rebalance rates in a budget neutral way that increases reimbursements for primary care providers and lowers reimbursements for overpaid specialties. While private insurance companies pay higher rates, this system would be expected to continue compensating providers at roughly the same overall rate that they are currently receiving. Why? This is partially because providers will now get paid Medicare rates for their Medicaid patients — a substantial raise. But it’s also because providers spend an enormous amount of time on billing and interacting with insurance companies that reduces their efficiency and takes away from time with patients. Some estimate that hospitals will spend $210 billion on average annually on these costs.

The nonpartisan Institute of Medicine estimates that these wasted expenses account for 13% of the revenue for physician practices, 8.5% for hospitals, and 10% for other providers. Together, the improved efficiency will save doctors time and money — helping significantly offset the revenue they will lose from getting rid of higher private insurance rates.

Under my approach, Medicare for All will sharply reduce administrative spending and reimburse hospitals at an average of 110% of current Medicare rates, with appropriate adjustments for rural hospitals, teaching hospitals, and other care providers with challenging cost structures. In 2017, hospitals that treated Medicare patients were paid about 9.9% less than what it cost to care for that patient. The increase I am proposing under Medicare for All will cover hospitals’ current costs of care — but hospital costs will also substantially decrease as a result of simpler administrative processes, lower prescription drug prices, the end of bad debt from uncompensated care, and more patients with insurance seeking care.

Of course, as Medicare currently recognizes, not every provider situation is the same, and my Medicare for All program maintains these base rate adjustments for geography and other factors. In my plan for Rural America, for example, I have committed to creating a new designation under Medicare for rural hospitals due to the unique challenges health systems face in rural communities. That’s why my plan allows for adjustments above the 110% average rate for certain hospitals, like rural and teaching hospitals, and below this amount for hospitals that are already doing fine with current Medicare rates. Universal coverage will also have a disproportionately positive effect on rural hospitals. Because people living in rural counties are more likely to be uninsured than people living in urban counties, these hospitals currently provide a lot of uncompensated care. Medicare for All fixes that problem. And I’ve previously laid out additional investments to increase the number of Community Health Centers and grow our health care workforce in rural and Native American communities, while cracking down on anti-competitive mergers that lead to worse outcomes and higher costs for rural communities.

We can also apply a number of common-sense, bipartisan reforms that have been proposed for Medicare. Today, for example, insurers can charge dramatically different prices for the exact same service based on where the service was performed. Under Medicare for All, providers will receive the same amount for the same procedure, saving hundreds of billions of dollars. We can also make adjustments to things that we know Medicare currently pays too much for — like post-acute care — by adjusting those payments down slightly while accounting for the patient’s health status, bringing health care costs down even more.

We will also shift payment rates so that we are paying for better outcomes, instead of simply reimbursing for more services. We build on the success of value-based reforms enabled by the Affordable Care Act, including by instituting bundled payments for inpatient care and for 90 days of post-acute care. Instead of paying providers for each individual service, bundled payments reimburse providers for an entire “episode” of care and have been shown to both improve outcomes and control costs. These bundles help ensure that a patient’s different providers all communicate because they are all tied to the same payment.

Restoring Health Care Competition

Health care consolidation has also contributed to rising health care costs. One analysis found that over 90% of metropolitan areas had health care provider markets that were either highly concentrated or super concentrated in 2016. And despite the same kinds of empty promises we see every time there’s industry consolidation — in this case, that bigger hospitals would lead to better care — the data have not borne this out. In fact, it’s the opposite: more competition between providers creates incentives to improve care, and that incentive will only increase under a Medicare for All system where quality, not price, is the main differentiator in the system.

Under Medicare for All, hospitals won’t be able to force some patients to pay more because the hospital can’t agree with their insurance company. Instead, because everyone has good insurance, providers will have to compete on better care and reduced wait times in order to attract more patients.

That’s why I will appoint aggressive antitrust enforcers to the Department of Justice and Federal Trade Commission and allow hospitals to voluntarily divest holdings to restore competition to hospital markets. I’ve also previously committed to strengthening FTC oversight over health care organizations, including non-profit hospitals, to crack down on anti-competitive behavior. And I will direct my FTC to block all future hospital mergers unless the merging companies can prove that the newly-merged entity will maintain or improve care.

Reining in out-of-control Prescription Drug Costs

Americans pay more for prescription drugs than anyone in the world — $333 billion in 2017 alone. Americans spent $1,220 per person on average for prescription drugs, while the next highest spending country, Switzerland, spent $963 per person. That’s not because Americans use more prescription medication — it’s because lax laws have allowed pharmaceutical companies to charge insurance companies and patients exorbitant rates. In a now-infamous example, when Turing Pharmaceuticals purchased the rights to the HIV medication Daraprim, the company raised the price of this life-saving drug from $13.50 per pill to a stunning $750 per tablet overnight. The price of insulin has skyrocketed, forcing people to risk their lives by rationing. And as prices continue to rise, more Americans are turning to Canada in search of affordable prices.

Reining in prescription drug costs should be a top priority for any President — and there’s no better way to do it than through Medicare for All. My administration will use a suite of aggressive policy tools to set a net savings target that will bring down Medicare prices for brand name prescription drugs by 70% and prices for generics by 30%, with an initial focus on more expensive drugs.

Under Medicare for All, the federal government would have real bargaining power to negotiate lower prices for patients. I will adopt an altered version of the mechanism outlined in the Lower Prescription Drug Costs Now Act which leverages excise taxes to bring manufacturers to the table to negotiate prices for both branded and generic drugs, with no drug exceeding 110% of the average international market price, but removes the limit of the number of drugs Medicare can negotiate for and eliminates the “target price” so Medicare could potentially negotiate prices lower than other countries.

If negotiations fail, I will use two tools — compulsory licensing and public manufacturing — to allow my administration to ensure patient access to medicines by either overriding the patent, as modeled in the Medicare Negotiation and Competitive Licensing Act, or by providing public funds to support manufacturing of these drugs, as modeled in my Affordable Drug Manufacturing Act. Medicare for All will also incentivize pharmaceutical companies to develop the drugs we need — like antibiotics, cancer cures, and vaccines.

And it’s not just about driving down drug prices. Making sure patients get important drug therapies up front that keep them healthy and cost a fraction compared to more severe treatment down the line can save money overall. Insurers, who may only cover individuals for a few years of their lives, see those investments in long-term health as a cost they’ll never recoup — so they have a financial incentive to deny patients these treatments. But Medicare for All covers each patient for their entire lifespan. There’s no perverse incentive to deny the prescriptions they need today because the long-term benefits to their health won’t benefit their current private insurance company.

Stemming the Growth of Medical Costs

Year after year, U.S. health spending has grown at rates above GDP growth, reaching a whopping 17.9% of GDP in 2017. Experts believe the changes to prescription drug spending and value-based payment systems that I’ve already outlined will bring growth rates in line with U.S. GDP, which CBO projects to be an average of 3.9% for the next decade. And if growth rates exceed this rate, I will use available policy tools, which include global budgets, population-based budgets, and automatic rate reductions, to bring it back into line.

Redirecting Taxpayer-Funded Health Spending

Through Medicaid and public health plans for state employees, state and local governments play a significant role in financing health care coverage in America. Under my approach to Medicare for All, we will redirect $6 trillion in existing state and local government insurance spending into the Medicare for All system. This is similar to the mechanism that the George W. Bush Administration used to redirect Medicaid spending to the federal government under the Medicare prescription drug program.

Under this maintenance-of-effort requirement, state and local governments will redirect $3.3 trillion of what they currently spend to support Medicaid and the Children’s Health Insurance Program and $2.7 trillion of what they currently spend on employer contributions to private insurance premiums for their employees into Medicare for All. Because we bring down the growth rate of overall health spending, states will pay less than they would have without Medicare for All. They’ll also have far more predictable budgets, resulting in improved long-term planning for state and community priorities.