Last week, when Bernie Sanders unveiled his new plan for single-payer healthcare in America, one of the biggest sins he laid at the feet of the insurance industry was its wastefulness. Much of what we spend on healthcare in this country pads the pockets of insurance executives and their companies' shareholders, he pointed out, while many Americans skip doctors' visits and forgo treatment even when they have insurance, because they can't afford co-pays and deductibles.


"Layers of bureaucracy associated with the administration of hundreds of individual and complicated insurance plans is stunningly wasteful, costing us hundreds of billions of dollars a year," Sanders wrote in an op-ed in the New York Times.

Indeed, by one measure, administrative costs account for more than 8 percent of spending on healthcare in the United States, more than double the average of industrialized countries around the world. Sanders's plan proposes a more streamlined, government-run system that would put the needs of people first, and he promises to do it in four short years if everything goes his way—which, of course, it won't.

But all of that bloated spending does something else single-payer fans would do well to grapple with: It creates jobs. Often, these are good jobs, especially for people with a modest education. And what happens to those people—who are mostly women—is something Democrats and progressives need to get a handle on if single-payer is ever going to get real traction in Washington.

About 14 years ago, when my dad was sick with cancer and unable to work, my mom found a job at the hospital in my rural hometown in Arkansas. The hospital was hiring everyone, it seemed; my mom found herself working with huge numbers of women who had only high school educations and had been out of the workforce for some number of years to take care of their children. This wasn't just an Arkansas thing—in many rural areas across America, the local hospital has traditionally been the largest local employer.


In addition to their own staffs, hospitals tend to create an ecosystem of doctors, pharmacists, physical therapists, and other medical professionals who need people to answer phones and keep track of patient files. My mom worked her way up to handle patient billing; another friend of mine moved back to our hometown and got a job at a local doctor's office as a file clerk. Nearly every time I step into a doctor's office in Arkansas and around the country, there are women behind the desk.

National stats paint a clear picture: More than 80 percent of people who call themselves file clerks, for example, are women. Physicians' offices and hospitals employ a lot of these people. While the wages aren't amazing—roughly $12 to 15 hourly on average—these are inside-an-office jobs that generally involve sitting at a desk, which is to say they are not menial.

The same is true for many of the other administrative jobs done in medical-office settings. There's a whole career path at for-profit colleges called "[medical billing](http://www.phoenix.edu/vr/rfi?&v7=medicalbillingandcoding&channel=srch&cid=SFGD9hWI&mktg_prog=HSC&keyword=medical billing&user2=nonbrand&provider=google&pvp_campaign=160126_4887_9_95&vrefid=gcp:se_43519:t_kwd-93093816:ag_26088667621:cp_347860741:n_g:d_c:cr_184506701220:fi_&gclid=CjwKCAjw3f3NBRBPEiwAiiHxGFM-8EDA1B7xbWAbapOTN3JJZXZIagOBIvv-ELDqF6ZMQyUyG5rTQhoCQdAQAvD_BwE#rc1)," and these jobs pay pretty well: more than $18 an hour nationally. Like many jobs in the healthcare industry, the long-term trends for job growth here are strong, especially since the Affordable Care Act boosted insurance enrollment. These are jobs that can lead to promotions and raises at a time when upward mobility is awfully hard to come by.

The problem is that a good portion of what many of these workers do is handle relationships and billing, and keep track of payments from insurance companies—the middle men Bernie Sanders wants to be rid of.


It's not necessarily true that these jobs would immediately vanish in a single-payer world. It's possible that hospitals and doctors' offices would need loads of clerks and billers to navigate the new Medicare-for-all system Sanders has proposed, which would cover every American. Or perhaps some of these jobs would become government gigs—better paying and with better benefits. And from a 30,000 foot perspective, it seems well and good that wasteful jobs are killed off if economic energy is better spent elsewhere, a kind of creative destruction with a progressive bent.

And to be clear, I support single-payer healthcare. "There is something fundamentally wrong when one of the richest and most powerful countries on the planet can't make sure that a person can afford to see a doctor when they're sick," Elizabeth Warren inveighed in announcing her support of Sanders's bill. "This isn't any way to live."

She's right: We would be better off as a society living in a more humane system like the one Sanders envisions.

But it's almost impossible to imagine such a massive shift in one-sixth of America's economy not hurting people along the way. And I fear that because the most likely victims are low-income women, this will be ignored—even if Democrats are the party that needs their votes. Just compare the possibility of single-payer, however farfetched, with the constant talk about what to do with coal miners—an occupation that only about 16,000 Americans could credibly call their own in 2015. There is no doubt coal-mining is an outdated profession that the country on a whole would be better off without—sending men underneath a mountain to dig out a material that poisons them and our atmosphere is not a job of the future.

In contrast, medical secretaries alone numbered more than half a million in 2016. A good portion of these people are low-income women who may be struggling to pay rent and feed their children. Where is the concern for them? Maybe it's that single-payer seems so unrealistic—and right now, with unified Republican control of Washington, it certainly is. But is it really less plausible so than, say, the self-driving truck threatening 1.7 million jobs? Maybe we romanticize this bureaucratic healthcare work less because it is the unsung labor of women who get up early every morning to get their kids to school—and need a job where they can clock in and out at specific times every day and be home to cook dinner. Or maybe we don't think much about these people because we still see all women's work as disposable.

Whenever America talks about how best to take care of workers displaced by a changing economy, there's always some gesture toward job training, or increasing access to education. And there's no doubt that more and better health care would lead to some new jobs in home-healthcare, nursing, nursing assistance, and other such gigs. But what if every woman doesn't want to become a nurse? What other jobs could people find, especially in rural America? I fear they would be low-end retail jobs that tend to be worse in almost every way: uncertain hours, low pay, constant standing.

If we lived in a country with a stronger social safety net, then a potential shock to an industry that employs many of our least-educated workers would be less concerning. But as long as we're living in the United States of America, the people cheering for single-payer need to come up with a plan to help the workers it threatens to leave behind.