What Medicare for All Would Actually Cost You, and What You’d Get

October 30, 2026

Every health system on earth rations care. Ours does it with a price tag. Medicare for All would do it with a calendar. The honest debate is about which kind of rationing we are willing to live with, and what it costs us to get there.

“Single payer” can mean a lot of things. But when people say it in American politics right now, they almost always mean one specific bill: Senator Bernie Sanders’ Medicare for All Act. It has the most cosponsors, the most media attention, and the most outside cost estimates. So that is the version I will model. I will also model a simpler alternative that gets far less attention: take Medicare exactly as it exists today and open it to everyone.

This week, not a rally speech. Not a scare piece. A model. Four variables that every serious analyst agrees are on the table: what it costs per person, what it does to your taxes, what it does to wait times, and who gets rationed and how.

The point is not to tell you what to think. The point is to show you the trade offs clearly enough that you can decide for yourself.

What the Sanders bill actually does

On April 29, 2025, Senator Bernie Sanders, Representative Pramila Jayapal, and Representative Debbie Dingell reintroduced the Medicare for All Act, S. 1506 and H.R. 3069. It is a true single payer bill. One public plan covers every person in the country.

The benefits are broad: primary care, hospital care, prescription drugs, dental, vision, and for the first time in this bill’s history, long term care with a preference for home and community based care over nursing facilities. Earlier versions phased in over four years and eliminated premiums, deductibles, and copays entirely.

No premiums. No deductibles. No copays. No network. That is the promise.

Here is what the bill does not include: a financing plan. Sanders has published a menu of options instead, which we will get to. And one more caution before we start. The major independent cost estimates were done on the 2016 through 2019 versions, before long term care was added. Any number you see should be read with that in mind. The 2025 bill is more generous than the bills that were scored.

Trade off one: what it costs per person

Start with the baseline. In 2024 the United States spent $5.3 trillion on health care, or $15,474 for every person, 18 percent of the economy. That number already includes everything: premiums, government programs, out of pocket costs, all of it.

The question is not whether Medicare for All is expensive. Sanders himself says it is. The question is whether it is more or less expensive than $15,474 per person.

The honest answer is that credible analysts land on both sides of zero.

The optimistic end. A 2020 study in The Lancet led by Alison Galvani at Yale estimated a 13 percent drop in national health spending, more than $450 billion a year. Applied to today’s baseline, that is roughly $13,460 per person. Worth knowing: Galvani was an unpaid informal advisor to Sanders’ office on the 2019 bill.
The middle. The Congressional Budget Office modeled five versions of single payer in 2020. Total national spending in 2030 ranged from $0.7 trillion lower to $0.3 trillion higher than current law. In other words, roughly a wash.
The pessimistic end. RAND projected a 1.8 percent increase for 2019, about $15,750 per person in today’s terms. The Urban Institute estimated the 2016 Sanders plan would raise total spending by $6.6 trillion over a decade. The Mercatus Center ran two scenarios: $2 trillion in savings if cost controls worked as designed, and a $3.3 trillion increase if they did not.

Why such a spread? Every estimate rests on the same three levers. Cut administrative overhead. Negotiate drug prices. Pay hospitals and doctors Medicare rates. The more of that you believe Congress will actually hold to, the cheaper the system gets.

That third lever is the one I watch most closely, and I will come back to it.

Here is the part that matters for your household. Almost every estimate agrees that total spending stays in the same neighborhood. What changes dramatically is who writes the check. Mercatus estimated $32.6 trillion in new federal spending over ten years. CBO put the federal increase at $1.5 to $3.0 trillion in 2030 alone. That money is not new spending. It is spending that moves from your paycheck deductions and your employer’s benefits budget onto the federal ledger.

The cheaper road: Medicare as it is, for everyone

Here is the version almost nobody is talking about. Skip the new benefits. Take traditional Medicare exactly as it works today and let every American enroll.

That is a much smaller program than the Sanders bill, because Medicare today is not that generous. It does not cover routine dental, vision, or hearing. It covers only short nursing home stays after a hospitalization, not ongoing long term care. And it has cost sharing: deductibles, 20 percent coinsurance on most outpatient care, and no annual out of pocket cap in traditional Medicare. That is why most seniors buy a supplemental plan or join Medicare Advantage.

The Sanders bill adds all of those benefits and removes all of that cost sharing. Here is how big those additions are. In 2024 the country spent $189 billion on dental care, and per CMS, $220 billion on nursing facilities and $169 billion on home health. Together that is roughly $578 billion, or about $1,700 per person, before vision and hearing.

Some of that money is already being spent by families and Medicaid. The bigger issue is what happens when it becomes free. CBO said the single most important factor pushing spending up under single payer is increased use of care, especially if long term services and supports are covered. Care that families now provide unpaid, at the kitchen table, becomes care the system pays for.

The best side by side comparison comes from the Urban Institute’s 2019 analysis, which modeled both versions:

Full Medicare for All (dental, vision, hearing, long term care, no cost sharing, everyone covered including undocumented immigrants): national health spending up about $720 billion in 2020 and $34 trillion in new federal spending over ten years. In 2020 terms, roughly $2,200 more per person than the current system.
Medicare for All “lite” (income related cost sharing, fewer added benefits, legal residents only): national health spending down about $209 billion in 2020 and about $17.6 trillion in new federal spending over ten years. In 2020 terms, roughly $630 less per person than the current system.

CBO found the same shape. Its cheapest single payer design, with cost sharing, lower provider rates, and no long term care, raised federal health spending by $1.5 trillion in 2030. Its most generous design, closest to the Sanders bill, raised it by $3.0 trillion. About half the price.

So the lean version is cheaper in every way that shows up on a budget. Here is what you give up for that:

Taxes: roughly half the new federal revenue the full bill needs. Still a very large tax increase, but a far more plausible one.
Cost per person: likely at or below today’s $15,474, instead of at or above it.
Wait times: less pressure. CBO found congestion is worst under designs with the lowest cost sharing, so keeping some cost sharing slows the rush of new demand.
Rationing: some rationing by price stays. A 20 percent coinsurance bill still stops some people from getting care. Dental and vision stay out of reach for many families. Long term care stays with Medicaid and with family members who cut back their work hours to care for a parent.
Supplemental coverage: private add on plans would very likely come back, the way Medigap exists today. That means some of the administrative savings shrink, and a two tier system creeps back in.

In other words, the lean version solves the coverage problem and most of the cost problem. It does not solve the affordability problem at the point of care. That is the trade.

Now back to the full bill, and what it does to your taxes.

Trade off two: your taxes go up, and your premiums go away

This is the part of the debate where people talk past each other. Opponents say taxes go up. Supporters say families save money. Both are true at the same time, for most people.

Sanders’ own financing paper lists two broad based “income based premiums.” A 7.5 percent payroll premium paid by employers, with the first $2 million of payroll exempt to protect small businesses. And a 4 percent income based premium paid by households, after a standard deduction of about $29,000 for a family of four.

Let me run that for a family of four earning $100,000 with employer coverage. Today’s figures come from KFF’s 2025 Employer Health Benefits Survey, where the average family premium hit $26,993 and the average worker paid $6,850 of it.

Today:

Worker share of premium: $6,850
Deductibles, copays, coinsurance: varies, often thousands
Employer cost for this worker: about $20,140 in premium

Under the Sanders option:

Worker share of premium: $0
Deductibles, copays, coinsurance: $0
New household income based premium (4 percent of income above about $29,000): about $2,840
Employer cost for this worker: $7,500 payroll premium

On paper, that family comes out several thousand dollars ahead, and the employer saves more than $12,000. Economists generally expect employer savings to flow back into wages over time. Generally. Not automatically.

Now the catch, and it is a big one.

Those two premiums do not come close to paying for the system. The Tax Policy Center noted that, if Urban Institute estimates are right, the two together cover only about one quarter of the cost. Sanders fills the rest with options aimed at the wealthy: higher top income tax rates, taxing capital gains like wages, a wealth tax, and eliminating the tax break for employer health benefits. The Committee for a Responsible Federal Budget has said that even all of the options combined would not cover the full cost.

To give you a sense of scale, CRFB estimated that any one of these alone could fund Medicare for All: a 32 percent payroll tax, a 25 percent income surtax, or a mandatory premium averaging $7,500 per resident. No one has proposed doing it that way. But it tells you how big the hole is.

The break even point also matters. Using Sanders’ own calculator, the Tax Policy Center found the savings disappear entirely for a married couple earning about $175,000 with $6,000 in annual medical expenses. Below that line, most families likely win. Above it, they likely pay more. That is not a flaw. As KFF’s Larry Levitt put it, more progressive financing is “a feature, not a bug.” But it is a choice, and voters deserve to see it plainly.

Trade off three: wait times

The moment you mention single payer, someone brings up Canada. So let’s bring up Canada.

The Fraser Institute, a Canadian free market think tank, surveys specialists every year. In 2025 Canadian patients waited a median of 28.6 weeks from a family doctor’s referral to treatment, the second longest in the survey’s history. For neurosurgery and orthopedics, the wait was close to 50 weeks.

That is real. It is also not the whole story.

We are not exactly fast here either. AMN Healthcare’s 2025 survey found it now takes an average of 31 days just to schedule a new patient appointment in the 15 largest U.S. metro areas, the longest since the survey began in 2004. Boston averages 65 days. That is the wait for the appointment, not the treatment, and it only counts people who can get in the door.

And Canada is not the only universal system. In the Commonwealth Fund’s international surveys, Canada consistently ranks at or near the bottom on wait times. But 46 percent of Canadians waited two months or more for a specialist, compared with about 15 percent in the Netherlands and 13 percent in Switzerland. Long queues are not a law of nature in universal coverage. They are a result of how much capacity a system funds and how it manages it.

That is exactly where the Sanders model has a real risk.

When the Congressional Budget Office modeled single payer, it found that the supply of care would not keep up with the new demand. More people covered. No copays. The result, in CBO’s words, would be increased congestion, including delays and forgone care, particularly in the versions with lower provider payment rates.

Here is why I take that seriously. Private insurers pay hospitals on average 254 percent of what Medicare pays for the same services. Medicare, meanwhile, pays hospitals less than it costs to treat its patients. MedPAC put the hospital Medicare margin at negative 12.1 percent for 2024. Hospitals survive today because commercial patients cover that gap.

Move every patient to a Medicare level rate and that cross subsidy disappears overnight. Some of it is fat, and the system can absorb it. Some of it is the margin that keeps a rural obstetrics unit open. If payment rates are set too low, capacity shrinks, and the queue grows. If they are set high enough to protect capacity, the savings shrink. That is the tension at the heart of the whole proposal.

Trade off four: who gets rationed, and how

“Rationing” is the word that ends conversations. I want to use it to start one.

We ration now. We just do not call it that.

We ration by price. In KFF polling this fall, 28 percent of adults said they skipped or postponed care they needed in the past year because of cost. Insurance does not fully protect you. Three in ten insured adults under 65 said the same. The Commonwealth Fund found that 23 percent of people insured all year were underinsured, and most of them had employer coverage.

We ration by paperwork. Medicare Advantage plans fully or partially denied 4.1 million prior authorization requests in 2024. Only 11.5 percent of those denials were appealed. Of the ones that were, 80.7 percent were overturned. Think about what that means. Most denials that get challenged turn out to be wrong, and most never get challenged.

We ration by coverage. Lose your job, age off a parent’s plan, lose Medicaid at redetermination, and access changes overnight.

To be fair to the current system, it also has a real strength. If you have good coverage, Americans have historically had some of the shortest waits in the developed world for specialists and elective surgery. That is part of what people fear losing, and it is a legitimate fear.

Medicare for All would end rationing by price. Nobody would skip a visit because of a copay. That is not a small thing. It is the reason I take this proposal seriously.

But it would not end rationing. It would change its shape. A single budget, set by Congress, would decide how many MRI machines, how many residency slots, how many operating room hours the country funds. When demand exceeds that, the rationing tool becomes time. The queue.

So the real question is not rationing versus no rationing. It is this: would you rather the system say “you can’t afford this,” or “you can have this, in four months”? The first falls hardest on the poor and the sick. The second falls on everyone, but more evenly, and it is more visible. Visible problems tend to get fixed. Invisible ones tend to get billed.

The model, side by side

Here is the whole thing on one page, four scenarios measured the same way. The two Sanders scenarios are not predictions. They are the range, depending mostly on one decision: how hard Congress holds the line on payment rates. The fourth is the lean version, Medicare as it exists today.

Today’s system

Spending per person: $15,474 (2024)
Who pays: employers, households, and government
Premiums and cost sharing: average family premium $26,993, worker pays $6,850 plus deductibles and copays
Provider pay: private plans pay about 254 percent of Medicare
Wait times: 31 days to schedule a new appointment in big metros; short specialist waits if well insured
How care is rationed: price, prior authorization, coverage gaps

Sanders Medicare for All, if cost controls hold

Spending per person: about $13,460 (13 percent lower, Lancet)
Who pays: mostly federal taxes
Taxes: new 4 percent household and 7.5 percent employer premiums, plus taxes on high earners
Premiums and cost sharing: none
Provider pay: near Medicare rates; hospitals lose the commercial cushion
Wait times: longer for elective care as demand rises (CBO)
How care is rationed: time and a national budget

Sanders Medicare for All, if cost controls slip

Spending per person: about $15,750 or more (RAND, Urban, Mercatus high case)
Who pays: mostly federal taxes, with a bigger gap to fill
Taxes: all of the above, plus broader middle class taxes or more debt
Premiums and cost sharing: none
Provider pay: rates raised to protect capacity; savings shrink
Wait times: depend on how much capacity is funded; Canada shows the downside, the Netherlands the upside
How care is rationed: time and a national budget, plus political fights over rates

Medicare as it is today, opened to everyone

Spending per person: likely at or below today (about $630 less per person in Urban’s 2020 “lite” model)
Who pays: mostly federal taxes, plus cost sharing at the point of care
Taxes: roughly half the new revenue the full bill needs
Premiums and cost sharing: Medicare style deductibles and 20 percent coinsurance; private supplemental plans likely return
Provider pay: near Medicare rates, same hospital pressure as the full bill
Wait times: less new demand than the full bill, so less congestion
How care is rationed: some price rationing remains; dental, vision, and long term care stay outside the system

Compare any line across the four and you see the same pattern. The full Sanders bill trades financial risk for capacity risk. The lean version splits the difference: less new tax, less new demand, and some of today’s price rationing left in place.

Where that leaves us

If you are a family earning under about $175,000, the Sanders model, on its own numbers, likely saves you money, as long as the rest of the financing lands on higher earners as promised. If you are uninsured, underinsured, or one diagnosis away from medical debt, it removes a threat that hangs over your life. Those are real gains, and the people dismissing them have usually never had to choose between a prescription and rent.

If you are well insured today and used to getting a specialist appointment within weeks, you have reason to ask hard questions about capacity. If you run a hospital, you have reason to ask what happens to your budget when your best payer disappears. Those are real concerns, and the people dismissing them have usually never had to balance a hospital budget.

The bill’s supporters and its critics are both describing something true. What neither side says often enough is that the outcome depends less on the words “Medicare for All” than on four decisions that come after: how generous the benefit is, what we pay providers, how much capacity we fund, and how we raise the money. The gap between the full bill and a plain Medicare expansion alone is roughly $16 trillion in federal spending over a decade.

Those are not slogans. They are budget lines. And that is where this debate should be happening.

What Medicare for All Would Actually Cost You, and What You’d Get

What the Sanders bill actually does

Trade off one: what it costs per person

The cheaper road: Medicare as it is, for everyone

Trade off two: your taxes go up, and your premiums go away

Trade off three: wait times

Trade off four: who gets rationed, and how

The model, side by side

Where that leaves us

Sources

The Medicare Door That Quietly Locks Behind You

Universal Access to Affordable Healthcare, without Medicare for All.

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