Medicare for All Is Making a Comeback

The situation is dire. Millions of people in the United States are months away from losing their health care. On January 1, dramatic changes to Medicaid outlined in the One Big Beautiful Bill Act, or OBBA, will take effect, impacting who is eligible for Medicaid. The new law excludes some groups completely (like most immigrants), introduces “community engagement” requirements (defined as 80 hours a month of work, volunteering, or school) for most people (apart from the elderly, children, and pregnant women), and requires renewals twice a year (as opposed to yearly). Some people have been impacted already (Nebraska implemented its changes on May 1 and began disenrolling people this month), and some will be kicked off their health care in October, when some previously qualified immigrants are made ineligible for Medicaid.

Though 92 percent of people should remain eligible for Medicaid coverage (through either a qualifying exemption or meeting the community engagement requirements), millions will still end up losing care. This is because of the substantial bureaucratic hurdles the OBBA introduces. In addition to increasing the intervals during which people must reverify their eligibility, the government has introduced an onerous process for documenting exemptions to the “community engagement” (i.e., work) requirements.

The process has become a maze of bureaucratic imposition. According to the Center for Medicaid and Medicare Services, you can get an exemption if you have a diagnosis that meets the criteria for being “medically frail.” However, the government has decided to go even further, potentially requiring attestation from a medical provider that an individual’s condition is sufficiently debilitating to keep them from working. The government cites “cancer” and “HIV/AIDS” as examples of conditions that need such a doctor’s note. A number of states have sued the federal government, arguing that this process differs from the law Congress wrote.

If just reading about this sounds confusing, that’s the point. Bureaucratic hurdles are designed with the intent to narrow the number of people who get Medicaid and therefore reduce how much the federal government spends on care. Instead, state governments will spend millions of dollars on administrative costs; data, software, consultants, and workers needed to process extra forms. When Georgia implemented work requirements for Medicaid in 2023, it cost $40 million to implement, and 80 percent of that cost was administrative. The OBBA changes will also have a profound economic cost: Some estimates suggest a loss of 1.2 million jobs and a decrease in gross domestic product by $154 billion when the law is fully implemented in 2029.

The counter to this chaos is simple—and it’s something we’re starting to hear about on the stump from Democratic candidates. As Vox’s Rachel Cohen reports, the health care reform debate has shifted in the direction of improving on the status quo and an openness to bigger ideas. And while candidates like Dr. Abdul El-Sayed, who Cohen notes is flexible on how the system might be improved, on the stump he keeps mentioning a more familiar idea: We could have a national health insurance program, better known as “Medicare for All.” Given the wreckage of the Trump era, Medicare for All has a lot to recommend.

In places such as Canada and the United Kingdom, you don’t worry about having to pay for lifesaving procedures, knowing that the government will pay for it. Getting procedures preapproved by an insurance bureaucrat is not part of the equation, and being buried in thousands of dollars of medical debt is not a concept that exists. These systems may not be perfect, but it is clear on key metrics that the United States does worse on health care than our industrialized counterparts. As just one example, the U.S. has worse life expectancy than most other high-income countries, yet we spend far more per capita than any other nation on health care.

The American health care system is no stranger to complexity. Even for those on private insurance, people are used to having to spend hours on the phone to get their care covered, doctors argue with insurance representatives on prior authorizations, and people have to navigate a labyrinth of numbers and lists—who is in network, what is the deductible, and what are the out-of-pocket maximums. If you buy health care on the Obamacare marketplace, it means having to decide what sort of trade-offs between coverage and cost you need to make when picking a plan. Americans hate dealing with insurance so much that one in four people will stay in a job they do not like in order to keep their commercial health insurance.

For the past few decades in the U.S., academics and politicians alike have treated Medicare for All as a “pie in the sky” idea. Despite studies showing that it would save billions of dollars and thousands of lives, this avenue has largely been unpursued, and instead, incremental steps have been taken to expand health care access. The Affordable Care Act, or ACA, was a monumental step in the right direction—among other things, it expanded Medicaid eligibility greatly.

During the Covid-19 pandemic, the federal government chose to continuously enroll people in Medicaid, keeping millions on health care (by avoiding needless bureaucracy), and Congress passed tax credits for the ACA marketplace (via the American Rescue Plan) and later extended them via the Inflation Reduction Act, bringing down the cost of monthly premiums dramatically. But in many cases, these wins turned out to be temporary. In 2023, continuous enrollment ended and millions were disenrolled from Medicaid. After Congress and the Trump administration let ACA subsidies lapse at the end of 2025, three million fewer people got their health care from the ACA marketplace.

Even though the ACA faced legal and legislative challenges, it has mostly survived. Now Medicaid is facing dramatic cuts. Medicare for All will similarly be an uphill battle, but the lesson we should garner from past experiences is that those who seek the complete privatization of health care in the United States will continue to be relentless at rolling back progress. Any attempt to expand health care or protect gains will be met with organized political resistance; so why not go for the moon? After all, polls show that Medicare for All is increasingly popular and, depending on the poll, has a majority or plurality support.

Medicare for All would not just be an easier experience for patients and doctors; it would also make dealing with a litany of American social problems a whole lot easier. Take treatment for substance use disorder, which is mostly funded through Medicaid. Currently, under the proposed “medical frailty rules,” someone who receives treatment for substance use disorder would be eligible for an exemption to the community engagement requirements, unless they have been in recovery for more than five years. Never mind the fact that recovery is a unique experience and challenging to define, this arbitrary policy could be disruptive and further complicate recovery and addiction treatment. It’s why treatment providers are so worried: having to focus on bureaucracy and paperwork to keep people covered, rather than spending time on care itself.

Contrast that with Medicare for All: A patient gets referred to treatment, the government pays for it with fewer bureaucratic steps, and there are no worries about jumping through hoops to continue to qualify for care. It would be a similar story across the health care system.

The next few years will be rough for the health care industry and patients alike. Hospitals will face enormous budgetary strains as they provide emergency care to people without insurance. Despite the best efforts of many states to keep people enrolled, millions will still likely lose care. Millions more will spend needless hours on bureaucracy and paperwork. While we may be a few years away from being able to implement a real universal health care plan, now is the time to start following the lead of El-Sayed and others to build the groundwork and start pitching it as a serious path forward. Academics, policymakers, professional societies, unions, and others should be relentless in their demand for Medicare for All.

Imagine a world where health insurance wasn’t tied to your job. Where employers didn’t have to negotiate with health insurance companies; where your monthly premium went toward taxes for an all-encompassing plan. A world where you don’t have to worry about making “too much money,” so that you lose your comprehensive health care (most people who work and receive Medicaid are in jobs that don’t provide insurance). That’s a world with Medicare for All.

Life is unaffordable for so many Americans, and managing your health can be difficult—but health care shouldn’t be a luxury that only the rich can afford. It really is that simple.