The shortcomings of the United States’ healthcare system truly put the country in a league of its own. It spends more than any other industrialized nation, both as a percentage of GDP and per capita, while having some of the worst health outcomes and failing to guarantee care to all of its population. The United States is the only rich nation in which people die or go into bankruptcy because they cannot afford healthcare. For the past two years, Democratic politicians and think tanks have released a wide variety of plans to correct these injustices.

The most popular and well-known of these proposals is Bernie Sanders’ Medicare-for-All bill, which would set up a single-payer system. All US citizens would be enrolled in a public (government) insurance plan, which would cover all necessary treatments and procedures without charging for co-pays or deductibles. Still, however, many physicians, specialists, and hospitals would remain in private hands. In other words, free health care for all, but not a government takeover. 

In order to achieve this, Sanders would eliminate all private insurance, which, in a recent poll, made support for the plan drop from 70 percent to 30 percent. As it turns out, most Americans with private insurance like their coverage want the option to keep it.

This poses a challenge to Democrats. People like Universal Healthcare in theory but turn sour on it once the details are fleshed out. It should be noted that even the Affordable Care Act, a moderate piece of legislation based on plans from the Conservative Heritage Foundation and former Republican Governor of Massachusetts Mitt Romney, barely survived a repeal attempt at the hands of a unified Republican government in 2017.

 What can Democrats do with this information? Is Medicare-for-All a lost cause, doomed to repeal the election cycle after its enactment?

As it turns out, single-payer is only one of few ways that other nations have achieved universal healthcare. It is true that Norway and Sweden have single-payer systems and the UK has even gone so far as to adopt, gasp, Socialized Medicine! (It should be noted that, decades in, none of these countries have fallen into economic collapse or a leftist dictatorship.) 

However, many countries do not provide care through a strictly single-payer system. Germany and Switzerland, for example, provide care mostly through (strictly regulated, non-for-profit, subsidized) private insurance. One might call these systems multi-payer. This was the idea behind the ACA, though Republicans and moderate Democrats killed provisions that would have ensured universal coverage.

Another option lies in a so-called two-tier system, which guarantees government insurance for certain things but leaves the rest to a private insurance market. 

Many nations which we call single-payer, like Denmark, Canada, and France should probably be considered part of this group. 95 percent of French people, two-thirds of Canadians, and 41 percent of Danes have private insurance plans. There are some concerns that two-tiered systems cause different outcomes for the rich and the poor, but all of these countries have mechanisms to reduce inequality of outcome. France is even considered by many to have the best health care system in the world. The US could do worse than to emulate them.

Which brings me to Medicare-for-All. It is often said that Medicare is a single-payer system for everyone over 65. This is not entirely true. About one-third of all Medicare beneficiaries choose private insurance instead of public insurance through a program called Medicare Advantage. 

Furthermore, a little under one-fifth of Medicare beneficiaries buy supplemental, so-called Medigap, insurance in addition to regular Medicare.

While Bernie Sanders’ bill does get rid of private insurance, real Medicare-for-All would most likely mean a mixed system of public and private insurance. The government would cover basic care, but private insurers could offer comparable plans to compete for enrollees. The incentive to match government prices would most likely reduce private profits in healthcare, if not eliminate it entirely. Everyone would be covered, and most people would be able to keep their private insurance. In order to reduce inequalities between the rich and the poor, the government could further subsidize the purchase of private alternatives for low-income households. Such a plan could balance Americans’ desire for universal coverage against their fear of change.