Senator Bernie Sanders and sixteen colleagues have introduced a new healthcare plan that they call “Medicare For All” (MFA), but what does “For All” really mean? Would MFA be a system through which everyone gets all of their medical care, or  a system that provides basic care at the government’s expense, while those who can pay their own way seek something better?

The practice of medicine outside the framework of MFA would be permitted under Title III of the bill, “Provider Participation,” especially Sec. 303, “Use of Private Contracts.” These give providers the choice of signing a contract with MFA in accordance with its rates and conditions, or opting out and contracting directly with patients. The only restriction seems to be that private contracts must be all or nothing. A provider could not accept the standard reimbursement for a treatment from MFA and then collect an additional fee from the patient.

The attractiveness of private contracts to providers and patients would depend, in large part, on how generously or tight-fistedly other provisions of MFA are implemented. In particular:

  • MFA guarantees coverage only of services deemed “medically necessary” (Sec. 202). Presumably, some kinds of alternative medicine, some treatments with unproved effectiveness, and some procedures of purely cosmetic value would be deemed not to be medically necessary. Private contracts would allow a market for such services to emerge. The tighter the interpretation of “medically necessary,” the larger the market.
  • Some providers might develop exceptional reputations (deserved or undeserved) for quality. Those who did so might well be able to earn more outside the MFA framework than within it. The lower MFA reimbursements, the greater the incentive to opt out.
  • MFA patients might encounter waiting periods for some procedures. Private contracts would offer a way to avoid the wait. If MFA administrators used rationing-by-waiting as a tool for cost control, this situation would become more common.

In short, Medicare for All could easily turn into Medicare for All Except Those Who Can Afford Something Better. Is that good or bad? Expect to hear more about this as the debate over the Sanders plan unfolds.