Single-Payer Healthcare (Medicare for All)

About 27 million U.S. residents had no health insurance at any point in 2024, an uninsured rate of 8.0 percent. National health expenditure reached $4.9 trillion in 2023, or 17.6 percent of GDP, the highest share among OECD countries. U.S. life expectancy in 2024 was 79.0 years, 3.7 years below the average of peer high-income countries. A single national health insurance program would replace the existing multi-payer system with one federally administered insurer covering every resident for medically necessary care.

What U.S. health coverage does

The U.S. health insurance system in 2024 covers most residents through a mix of programs determined by employment, age, income, and federal or state eligibility rules. Employment-based private coverage covered 53.8 percent of the population, Medicare 19.1 percent, Medicaid 17.6 percent, direct-purchase private coverage 10.7 percent, TRICARE 2.8 percent, and VA coverage 1.2 percent. Approximately 8.0 percent of residents, about 27 million people, had no coverage at any point in 2024.

Cost-sharing in private and public coverage consists of premiums, deductibles, copayments, and coinsurance. The KFF Health Care Debt Survey reported in 2022 that 41 percent of U.S. adults had some amount of health care debt and that 3 percent of those with health care debt declared personal bankruptcy in the prior five years citing medical bills as a contributing factor. Administrative costs in the U.S. health care system, measured by Himmelstein and Woolhandler in a 2020 Annals of Internal Medicine study using 2017 spending data, accounted for 34 percent of total expenditures, or about $1.1 trillion. Per capita administrative spending in the United States was about $2,497 in 2017, compared with about $551 in Canada.

The statute

Executive action cannot, on its own, establish a national insurance program. A single-payer program requires authorizing statute. The Medicare for All Act (H.R. 3069 / S. 1506, 119th Congress), introduced April 29, 2025, by Sen. Bernie Sanders and Reps. Pramila Jayapal and Debbie Dingell, provides the legislative vehicle. If enacted with the provisions below, it would establish the program:

• Establish a national health insurance program administered by HHS, with automatic enrollment of every U.S. resident at birth or upon establishing residency.
• Cover hospital services, primary and specialty care, prescription drugs, mental health and substance use treatment, dental and vision services, long-term care and supports, gender-affirming care, and reproductive care including contraception and abortion.
• Prohibit cost-sharing for covered services. No premiums, deductibles, copayments, or coinsurance.
• Restrict private insurers and employers to offering supplemental coverage that does not duplicate the program’s benefits.
• Require HHS to negotiate prescription drug prices and to set provider payment rates through annual rate-setting consistent with existing Medicare methodology.
• Phase in coverage starting one year after enactment for residents age 55 and older, residents age 18 and younger, and existing Medicare beneficiaries; allow other residents to buy into the program during the transition.
• Finance the program through progressive taxation specified in companion revenue legislation, replacing premium and out-of-pocket spending currently borne by households and employers.

Precedent

Federal precedent for single-payer insurance exists in current law. Title XVIII of the Social Security Act, enacted as part of the Social Security Amendments of 1965, established Medicare as a federal single-payer insurance program for residents age 65 and older. Title XIX of the same Act established Medicaid as a federal-state program for low-income residents. By the end of 1968, Medicare provided hospital insurance to 19.6 million people. The 2025 Medicare for All Act extends the existing Medicare administrative architecture to the full population.

Several peer countries operate national single-payer systems with comparable design features. Canada’s Canada Health Act of 1984 placed publicly funded universal coverage on a federal statutory footing under five principles: public administration, comprehensiveness, universality, portability, and accessibility. The United Kingdom’s National Health Service Act of 1946 established the NHS, which began operations on July 5, 1948, providing comprehensive medical services free at the point of use, financed through general taxation. Taiwan’s National Health Insurance, enacted in 1994 and operational from March 1995, integrated 13 separate insurance schemes into a single national plan; population coverage reached 92 percent within the first year and 99.9 percent by 2023. Direct administrative cost in Taiwan’s program is approximately 2 percent of program expenditures.

The Congressional Budget Office’s 2022 analysis “Economic Effects of Five Illustrative Single-Payer Health Care Systems” projected that a single-payer program would reduce administrative spending in the health sector by approximately 1.8 percent of GDP by 2030, with hospital administrative spending falling from 19 percent of revenue to 12 percent and physician administrative overhead falling from 15 percent to 9 percent. A 2020 study published in The Lancet by Galvani and colleagues estimated that a single-payer system would reduce national health expenditure by 13 percent, or about $450 billion per year, and would prevent about 68,000 deaths and 1.73 million life-years lost annually compared with the existing system.

First 100 days

The Medicare for All Act and its companion revenue legislation must be enacted by Congress for any of the steps below to take effect. The schedule presumes a coordinated executive-legislative effort with floor consideration in the first month and final passage by day ninety.

Day one. The administration transmits the Medicare for All Act and the companion revenue legislation to Congress and requests immediate consideration. HHS begins enrollment infrastructure planning. The Centers for Medicare & Medicaid Services publishes a draft enrollment timeline. The Department of Labor opens coordination with employers on the wind-down of employer-sponsored coverage during the buy-in period.

Day thirty. Both chambers complete committee markup and floor consideration of the Medicare for All Act and the companion revenue legislation. HHS publishes the proposed national fee schedule for provider payments, the prescription drug price negotiation framework, and the rules restricting private insurance to non-duplicative supplemental benefits. CMS publishes the operational manual for automatic enrollment.

Day ninety. Congress passes the Medicare for All Act and the companion revenue legislation, and the President signs both into law. CMS opens initial enrollment for residents 55 and older, residents 18 and younger, and existing Medicare beneficiaries. The buy-in period for other residents begins.

Effect of the program

A single national health insurance program covering all U.S. residents removes private insurance enrollment, employer eligibility, age, and income from the determinants of access to medically necessary care. Coverage is tied to residency, and enrollment is automatic. Provider payment is administered by a single payer at federally negotiated rates, and prescription drug prices are negotiated nationally. Administrative spending across the health sector, measured at 34 percent of total expenditures in 2017, would decline toward the 1.8-percent-of-GDP reduction projected by CBO and the 13-percent reduction in total national health expenditure projected in the 2020 Lancet analysis. There is no cost-sharing at the point of care for covered services.