The Medicare for All plan would leave intact the current infrastructure of doctors, hospitals and other health care providers, but nationalize the health insurance industry. Nearly all the money individuals and employers currently pay into the system as well as much of the money states pay would, under Sanders’ plan, instead go through the federal government.

Sen. Bernie Sanders has been pushing a single-payer health care system for decades. It’s the centerpiece of his vision for a more democratic socialist America. There are several such proposals for a single-payer system, but what’s below is from the 100-page draft bill most recently introduced, with tweaks, by Sanders in 2019.

S. 1129 To establish a Medicare-for-all national health insurance program. IN THE SENATE OF THE UNITED STATES APRIL 10, 2019 Mr. SANDERS (for himself, Ms. BALDWIN, Mr. BLUMENTHAL, Mr. BOOKER, Mrs. GILLIBRAND, Ms. HARRIS, Mr. LEAHY, Mr. MARKEY, Mr. MERKLEY, Mr. SCHATZ, Mr. UDALL, Ms. WARREN, Mr. WHITEHOUSE, Ms. HIRONO, and Mr. HEINRICH) introduced the following bill; which was read twice and referred to the Committee on Finance From page 1

The first thing to note is that Sanders’ proposal has only 14 co-sponsors in the Senate. That’s not even a majority of Democrats. That’s less than a third of the 60 votes usually required to overcome a filibuster and pass major legislation, although he has said he would use budget rules to maneuver around the practice of the filibuster in order to get Medicare for All passed.

SEC. 102. UNIVERSAL ENTITLEMENT. (a) IN GENERAL.—Every individual who is a resident of the United States is entitled to benefits for health care services under this Act. The Secretary shall promulgate a rule that provides criteria for determining residency for eligibility purposes under this Act. (b) TREATMENT OF OTHER INDIVIDUALS.—The Secretary— (1) may make eligible for benefits for health care services under this Act other individuals not described in subsection (a) and regulate their eligibility to ensure that every person in the United States has access to health care; and (2) shall promulgate a rule, consistent with Federal immigration laws, to prevent an individual from traveling to the United States for the sole purpose of obtaining health care services provided under this Act. From page 4

In Sanders’ proposal, everyone who is a US resident, including undocumented immigrants, gets coverage. That would be a likely point of contention with this plan. There is a prohibition on traveling to the US for free medical care.

SEC. 103. FREEDOM OF CHOICE. Any individual entitled to benefits under this Act may obtain health services from any institution, agency, or individual qualified to participate under this Act. From page 5

Medicare for All is meant to be an extremely egalitarian proposal in which everyone has access to any provider. That’s certainly not the current system in the US, in which there are extreme differences based on the quality of a patient’s insurance and wealth.

SEC. 104. NON-DISCRIMINATION. (a) IN GENERAL.—No person shall, on the basis of race, color, national origin, age, disability, or sex, including sex stereotyping, gender identity, sexual orientation, and pregnancy and related medical conditions (including termination of pregnancy), be excluded from participation in, be denied the benefits of, or be subjected to discrimination by any participating provider as defined in section 301, or any entity conducting, administering, or funding a health program or activity, including contracts of insurance, pursuant to this Act. From page 5

This is a general nondiscrimination statement except it includes the language “including termination of pregnancy.” The issue of how the federal government should (or should not) provide access to abortion nearly sank passage of the Affordable Care Act in 2009 and 2010. Here Sanders appears to go in the opposite direction and enshrine abortion rights in the language.

The bill also says the health and human services secretary will lay out a system by which claims of discrimination should be adjudicated and that courts can grant damages.

SEC. 105. ENROLLMENT. (a) IN GENERAL.—The Secretary shall provide a mechanism for the enrollment of individuals eligible for benefits under this Act. The mechanism shall— (1) include a process for the automatic enrollment of individuals at the time of birth in the United States or upon the establishment of residency in the United States; From page 6

Americans would be automatically enrolled for benefits at birth or when they move to the US. A subsequent section describes a Universal Medicare Card.

SEC. 106. EFFECTIVE DATE OF BENEFITS. (a) IN GENERAL.—Except as provided in subsection (b), benefits shall first be available under this Act for items and services furnished on January 1 of the fourth calendar year that begins after the date of enactment of this Act. From page 7

Sanders envisions a four-year transition period. Children under 19 would get universal coverage one year after the bill is signed into law. Everyone else would have the option of keeping their current coverage during the transition or of buying into Medicare or a transitional public plan. Four years to transition from a mostly private system to an entirely public one would be a quick pace. Automatic enrollment is also a departure from the current Medicare system. There would be no precedent for administering this kind of federal program in the US.

SEC. 107. PROHIBITION AGAINST DUPLICATING COVERAGE. (a) IN GENERAL.—Beginning on the effective date described in section 106(a), it shall be unlawful for— (1) a private health insurer to sell health insurance coverage that duplicates the benefits provided under this Act; or (2) an employer to provide benefits for an employee, former employee, or the dependents of an employee or former employee that duplicate the benefits provided under this Act. From page 8

This is the most controversial element of this bill. Sanders would make it illegal to sell private health insurance that covers the benefits offered by Medicare for All. This provision would certainly be subject to lawsuits. A subsequent section says additional benefits not covered by Medicare for All (cosmetic surgery, for instance) could be covered by a supplemental insurance plan.

This is the nationalization of an industry in an unprecedented way. It’s important to note here that about one-third of the American seniors who currently get Medicare get it through private Medicare Advantage plans offered by health insurance companies. Those plans would go away.

SEC. 201. COMPREHENSIVE BENEFITS. (a) IN GENERAL.—Subject to the other provisions of this title and titles IV through IX, individuals enrolled for benefits under this Act are entitled to have payment made by the Secretary to an eligible provider for the following items and services if medically necessary or appropriate for the maintenance of health or for the diagnosis, treatment, or rehabilitation of a health condition: From page 8

There is a generous list of covered health, vision and dental benefits, and some long-term care benefits including:

(1) Hospital services, including inpatient and outpatient hospital care, including 24-hour-a-day emergency services and inpatient prescription drugs. (2) Ambulatory patient services. (3) Primary and preventive services, including chronic disease management. (4) Prescription drugs, medical devices, biological products, including outpatient prescription drugs, medical devices, and biological products. (5) Mental health and substance abuse treatment services, including inpatient care. (6) Laboratory and diagnostic services. (7) Comprehensive reproductive, maternity, and newborn care. (8) Pediatrics, including early and periodic screening, diagnostic, and treatment services (as defined in section 1905(r) of the Social Security Act (42 U.S.C. 1396d(r))). (9) Oral health, audiology, and vision services. (10) Short-term rehabilitative and habilitative services and devices. (11) Emergency services and transportation. (12) Necessary transportation to receive health care services for individuals with disabilities and low income individuals. (13) Home and community-based long-term services and supports From page 9

The HHS secretary would be in charge of regularly recommending improvements and adjustments to the benefits package for Congress to consider. States can offer their residents supplementary benefits, but can’t offer their own version of Medicare for All benefits.

SEC. 202. NO COST-SHARING. (a) IN GENERAL.—The Secretary shall ensure that no cost-sharing, including deductibles, coinsurance, copayments, or similar charges, be imposed on an individual for any benefits provided under this Act, except as described in subsection (b). (b) EXCEPTIONS.—The Secretary may set a cost sharing schedule for prescription drugs and biological products— From page 13

People who get Medicare for All would not pay for any part of their health care except, in some cases, up to $200 for prescription drugs for individuals making more than $25,200 annually or families of four making more than $52,400 (200% of the federal poverty level in 2020). The average cost of drugs per person per year in the US is currently more than $1,000 for drugs bought at pharmacies, but the average out-of-pocket spending per person is only $144. However, the current costs are concentrated more on some people than others. This would spread those costs.

SEC. 203. EXCLUSIONS AND LIMITATIONS. (a) IN GENERAL.—Benefits for services are not available under this Act unless the services meet the standards specified in section 201(a), as defined by the Secretary. (b) TREATMENT OF EXPERIMENTAL SERVICES AND DRUGS.— (1) IN GENERAL.—In applying subsection (a), the Secretary shall make national coverage determinations with respect to services that are experimental in nature. From page 14

The HHS secretary has a lot of power in this plan to determine what is covered, including what experimental and new services are covered. Currently, for people with private health insurance, those determinations are made by insurance companies.

SEC. 204. COVERAGE OF INSTITUTIONAL LONG-TERM CARE SERVICES UNDER MEDICAID. Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) is amended by inserting the following section after section 1946: “STATE PLAN FOR PROVIDING INSTITUTIONAL LONG TERM CARE SERVICES From page 15

Sanders changed his plan in 2019 to include home- and community-based long-term care after lobbying by disability rights groups and to come more in line with a single-payer insurance plan put forward by progressives in the House. But this portion of his proposal, which stretches over multiple pages, would rely on a state plan to provide institutional long-term care services. Separately, he gives states the ability to set their own standards under Medicare for All as long as they are not less generous than the federal system.

SEC. 301. PROVIDER PARTICIPATION AND STANDARDS. (a) IN GENERAL.—An individual or other entity furnishing any covered service under this Act is not a qualified provider unless the individual or entity— (1) is a qualified provider of the services under section 302; (2) has filed with the Secretary a participation agreement described in subsection (b); and (3) meets, as applicable, such other qualifications and conditions with respect to a provider of services under title XVIII of the Social Security Act as described in section 1866 of the Social Security Act (42 U.S.C. 1395cc). From page 22

Sanders promises Americans access to the doctors they currently see and more. But his system assumes that doctors will take part. Just as many doctors do not take part in the current Medicare and insurance systems, some would likely sidestep the government program and seek payment on a fee-for-service basis outside Medicare for All.

While providers would have protections under the plan, they would also have responsibilities. And it is an either-or scenario. Either they enroll as a Medicare for All provider or they go outside the system.

SEC. 303. USE OF PRIVATE CONTRACTS. (a) IN GENERAL.—Subject to the provisions of this subsection, nothing in this Act shall prohibit an institutional or individual provider from entering into a private contract with an enrolled individual for any item or service— From page 29

The bill does specifically envision private agreements — not insurance — between individuals and providers or groups of providers outside of Medicare for All. But providers, once they enter into such agreements, cannot participate in the government program for a year.

SEC. 401. ADMINISTRATION. (a) GENERAL DUTIES OF THE SECRETARY.— (1) IN GENERAL.—The Secretary shall develop policies, procedures, guidelines, and requirements to carry out this Act, including related to— (A) eligibility for benefits; (B) enrollment; (C) benefits provided; (D) provider participation standards From page 33

This would be a massive new federal bureaucracy, replacing, by some estimates, 2 million US insurance and health industry jobs. Setting up, enforcing and evolving a health care system for about 320 million people and transitioning more than 200 million from a private system to a public one would be a gargantuan undertaking. Sanders’ proposal imagines a regional administration system that would coordinate individual states and filter up to the HHS secretary, who would be in charge of setting policies. An official ombudsman would collect and hear grievances.

SEC. 411. APPLICATION OF FEDERAL SANCTIONS TO ALL FRAUD AND ABUSE UNDER UNIVERSAL MEDICARE PROGRAM. The following sections of the Social Security Act shall apply to this Act in the same manner as they apply to State medical assistance plans under title XIX of such Act: From page 44

When the federal government takes over trillions of dollars in spending, there is a real danger of waste, fraud and abuse. Sanders envisions applying existing protections that govern Medicaid funding to protect this Medicare for All investment. There are also sections that mandate the creation of an annual health care budget and a focus on cost containment.

A key selling point of a single-payer system is that the government can keep costs down by setting prices to pay doctors, hospitals and drug companies. It’s also why the industries will fight this tooth and nail. It would almost definitely set lower payments to doctors and hospitals than private insurers. More on that in a moment.

(4) TEMPORARY WORKER ASSISTANCE.—For up to 5 years following the date on which benefits first become available as described in section 106(a), up to 1 percent of the budget may be allocated to programs providing assistance to workers who perform functions in the administration of the health insurance system and who may experience economic dislocation as a result of the implementation of this Act. From page 47

By replacing the entire health insurance industry, the government could displace 2 million workers, according to some estimates. Some of those would find jobs in the new government systems. Others could be eligible for up to five years of temporary assistance.

(5) RESERVE FUND.—The Secretary shall establish and maintain a reserve fund to respond to the costs of treating an epidemic, pandemic, natural disaster, or other such health emergency. From page 48

Coronavirus? Hurricane? Earthquake. The government should be prepared.

(a) APPLICATION OF PAYMENT PROCESSES UNDER TITLE XVIII.—Except as otherwise provided in this section, the Secretary shall establish, by regulation, fee schedules that establish payment amounts for benefits under this Act in a manner that is consistent with processes for determining payments for items and services under title XVIII of the Social Security Act From page 49

One fact of US health care is that American doctors make more money than their counterparts in other countries. There are many reasons for that, but one clear way to contain the cost of health care is to contain the amount doctors are paid. Granted, they should have a much simpler time being reimbursed under a single-payer system and more of their time will be spent treating patients. But their bottom lines might also shrink. That’s one reason some doctors could opt out. Hospitals too. In the current system, private insurance pays higher rates to hospitals and doctors than Medicare and Medicaid do.

SEC. 613. OFFICE OF PRIMARY HEALTH CARE. (a) IN GENERAL.—There is established within the Agency for Healthcare Research and Quality an Office of Primary Health Care, responsible for coordinating with the Secretary, the Health Resources and Services Administration, and other offices in the Department as necessary, From page 54

The federal government would take a much bigger role in assessing the landscape of educating doctors and determining how many specialists are needed in a given field. The US currently has a system that prioritizes specialization over general medicine. And that’s not saving anyone money.

SEC. 614. PAYMENTS FOR PRESCRIPTION DRUGS AND APPROVED DEVICES AND EQUIPMENT. (a) NEGOTIATED PRICES.—The prices to be paid for covered pharmaceuticals, medical supplies, and medically necessary assistive equipment shall be negotiated annually by the Secretary. From page 55

Drug companies are going to fight this with all their might (and they have a lot of money). Instead of setting a price in the market for a drug, they’d have fewer people to negotiate with and may have to accept what the government gives them. It’s no coincidence that Americans pay a lot more for the same prescription drugs than people in countries with single-payer systems. So, yes, this would remove some of the profit motive of the pharmaceutical industry. On the other hand, it’s not at all an agreed-upon fact that drug companies should be able to charge exorbitant prices for lifesaving drugs.

SEC. 701. UNIVERSAL MEDICARE TRUST FUND. (a) IN GENERAL.—There is hereby created on the books of the Treasury of the United States a trust fund From page 56

This is a massive new program and paying for it isn’t going to be easy. Sanders has plenty of ideas, however. For starters, everything that goes into the Medicare trust fund would now go into this new, larger fund. So would money that now goes toward the health care of veterans and pays states to provide Medicaid.

The federal government gives tax breaks to employers for providing health insurance. With those benefits now outlawed, the savings in tax breaks would go into the trust fund.

But it’s certainly not clear how the numbers would add up. Sanders has proposed a menu of options to offset the costs of this program. They are not all outlined in this text. The dollars and cents of this are less important to Sanders than the moral imperative. Here’s a look at Sanders’ math.

SEC. 901. RELATIONSHIP TO EXISTING FEDERAL HEALTH PROGRAMS. From page 63

There are many pages of this bill that deal with sunsetting the bramble of ways the US government currently helps Americans with health care — Medicare, Obamacare, Tricare, federal employee benefits and more — and unifying them in this new plan.

TITLE X—TRANSITION 19 Subtitle A—Transitional Medicare Buy-In Option and Transitional Public Option From page 67

During the four years during which Sanders envisions the Medicare for All system being set up, there is a rolling admission to traditional Medicare, with its low premiums, starting with 55-year-olds in the first year after the law is passed, 45-year-olds in the second and 35-year-olds in the third.

There would similarly be a public health insurance option offered on the individual market for those not yet qualified for Medicare.

The rest of the bill concerns this transition period. It zeroes out some Medicare premiums during that period and accounts for subsidies some Americans get under Obamacare.