
I wanted to comment on Ramesh Ponnuru’s remarks on “Medicare for All” in a recent Washington Post op-ed before it disappeared. In the op-ed Mr. Ponnura sketches four reasons a national single-payer healthcare system modeled on Medicare won’t work. His reason are (in sequence):
- It would require a substantial increase in the taxes paid by people earning middle incomes which might or might not be made up by savings in payments of private healthcare insurance.
- Savings aren’t likely to materialize.
- The systems most similar to “Medicare for All” (Canada’s and Britain’s) have long wait times, particularly for specialists.
- It would require the abandonment of employer-subsidized and private healthcare insurance and Medicare Advantage.
I would like to propose several other issues. First, the costs of such a plan are wildly understated. The graph at the top of the page illustrates the real growth in real Medicare spending from inception to date. That is orders of magnitude faster than was estimated when it was originally enacted far exceeding the original projections, which proved not merely inaccurate but systematically and persistently optimistic. Here’s the real growth in Affordable Care Act subsidies since its inception:

Those, too, have grown considerably faster than estimated at the time.
When healthcare spending comprised 3% or 5% of spending, a five-fold increase would have been painful but, possibly tolerable. Now that it’s 16% of spending a ten-fold increase in healthcare spending, as occurred with Medicare, isn’t arithmetically possible. A five-fold increase is hypothetically possible but absurd. The implication is that for such a plan to work costs must be controlled. Growth on the scale Medicare experienced cannot be repeated without overwhelming the rest of the fiscal system and, indeed, the economy.
The second issue is that Congress has demonstrated that it is unwilling to control healthcare costs. That was proven dispositively by the experience with Medicare SGR, demonstrated repeatedly by Congress.
The third issue is that once implemented such a plan would be irreversible. There would be no alternative system to return to. Once private and employer-based systems are displaced, rebuilding them would be economically and politically prohibitive.
The relevant question is not why Medicare spending exceeded projections. The relevant question is why we should believe that future projections will be more accurate than past ones. Medicare and ACA estimates were produced by serious analysts using the best available data, yet both proved systematically optimistic. That shifts the burden of proof. Proponents of a vastly expanded system must identify concrete, politically sustainable mechanisms that will prevent the recurrence of those errors. Absent that, assurances of cost control are not evidence. They are repetition.
I don’t oppose a national single-payer healthcare system in principle. I oppose it in practice. For any such proposed system to work it must be structured to align the incentives of consumers, providers, and administrators. It is not sufficient to assert savings from administrative simplification or bargaining power. Proponents must identify specific mechanisms that (1) constrain provider behavior, (2) are politically sustainable, and (3) have not historically been reversed under pressure. As the graphs above clearly show more than blithe assurances are required. The problem is not that we lack ideas for controlling healthcare costs. The problem is that every serious attempt to implement them has been reversed when it encountered political reality.






