The United States spends $14,885 per person per year on healthcare — nearly 2.5 times the OECD average. Every other wealthy democracy has universal coverage of some kind. None spend what the US spends. American life expectancy is 79 years — 3.7 years below the comparable country average, and the gap is widening. Infant mortality ranks 32nd of 38 OECD countries. Preventable deaths: 238 per 100,000 versus an OECD average of 158.
The country paying the most is getting among the worst outcomes. That is the starting point for any honest conversation about healthcare.
I support Medicare for All. Single-payer, universal coverage, zero copays, zero deductibles, zero premiums. Every resident covered. Here is why, and here are the objections I take seriously.
The number you hear most often is $32 trillion in new federal spending over ten years. That number comes from the Mercatus Center — a Koch-funded think tank that published it in 2018 to make Medicare for All look unaffordable. What the study's own tables showed, if you read them, is that total national health spending decreases — by roughly $2 trillion over ten years. Federal spending goes up. Private spending (premiums, copays, deductibles) goes down by more. Net: savings.
The average family with employer-sponsored insurance pays $6,850 per year in premiums, faces a deductible of nearly $1,900, and can hit an out-of-pocket maximum above $6,000. Total exposure before insurance becomes meaningful: potentially $12,000 to $17,000 per year on top of what the employer pays. Under Medicare for All, that goes to zero at the point of service, replaced by a 4% income tax exempt on the first $29,000 of earnings. For most working families, the math is better. The question is whether you believe the money you currently send to an insurance company is meaningfully different from the money you would send to the government. The insurance company takes 15–20% for overhead and profit. Medicare's administrative overhead is roughly 2%.
Rural hospitals. Medicare currently pays hospitals about 99 cents on the dollar of their costs. Private insurance pays 140–180% of Medicare rates. If every payer becomes Medicare overnight, hospitals that depend on that private insurance surplus — especially rural and safety-net hospitals — face genuine financial stress. 140 rural hospitals have closed since 2010 under the current system. The risk is real both ways. The answer is a negotiated reimbursement floor during the transition — not Medicare rates on day one, but a managed convergence that doesn't bankrupt the hospitals that serve the people who need them most.
Insurance industry jobs. Roughly 450,000 to 500,000 people work in health insurance underwriting, billing, and claims processing. A four-year transition would eliminate most of those jobs. The healthcare system would expand dramatically and absorb many of those workers, but the disruption is concentrated in specific communities and specific lives. Transition assistance needs to be specific and funded — not a footnote in a bill, but a program with the same seriousness as the coverage expansion itself.
Capacity and wait times. When 27 million uninsured Americans suddenly have coverage, demand for services increases. If supply — doctors, specialists, hospital beds — doesn't grow as fast, wait times increase. This is the real Canadian problem: not the existence of single-payer, but the failure to invest in capacity alongside coverage. The bill prioritizes primary care funding, but specialist access in rural areas is already a crisis. Coverage without capacity is a promise you can't keep.
Pharmaceutical innovation. The industry argues that price controls reduce R&D incentives. There is theoretical weight to this at scale, though the early evidence from the Inflation Reduction Act's limited drug price negotiation shows no decline in early-stage development. The deeper dysfunction: the US funds a substantial portion of pharmaceutical R&D through NIH grants — public money — and then pays full market price for the resulting drugs. That is not innovation policy. It is subsidy without leverage.
Political feasibility. Medicare for All has never come to a floor vote in Congress. The insurance industry will spend limitlessly to prevent it. This is real. It is not an argument against the policy — it is an argument about strategy and sequencing. I am telling you what the evidence says is right. Whether it passes this year or in twenty years is a question for the people who show up to vote and the candidates who show up to run.
This is not an academic debate. Enhanced ACA subsidies have expired. Premiums rose 114% for subsidized enrollees. Medicaid work requirements are removing millions from coverage. The CBO projects 16.5 million fewer people covered by 2032 compared to 2025. The coverage floor is being actively excavated. Every month this continues, people die of treatable conditions because they cannot afford to see a doctor.
The question is not whether America can afford Medicare for All. The question is whether America can afford to keep spending 2.5 times what every other wealthy country spends while getting worse outcomes and leaving 27 million people with nothing. The system we have is not the affordable option. It is the most expensive healthcare system in the world, and it does not work.