Health care, including the concept of “Medicare for All,” will be a prominent issue for Democrats eyeing presidential bids in 2020. Potential candidates include Sens. Kirsten Gillibrand (D-N.Y.), Cory Booker (D-N.J.), and Elizabeth Warren (D-Mass.). One complication is that the term “Medicare for All” doesn’t have a single definition. To Sen. Bernie Sanders (I-Vt.), it means the elimination of private insurance and the establishment of a single national program. To others, it means an option to buy into the existing Medicare program, which many Republicans support. The extremely polarizing single-payer concept proposed by Sen. Sanders is gaining steam.

According to Sen. Sanders in the essay “Medicare for All: Leaving No One Behind,” his plan would create a federally administered single-payer healthcare program, or comprehensive coverage for all Americans. It would cover the entire continuum of health care, from inpatient to outpatient care; preventive to emergency care; primary care to specialty care, including long-term and palliative care; vision, hearing, and oral health care; mental health and substance abuse services; and prescription medications, medical equipment, supplies, diagnostics, and treatments. Patients would be able to choose healthcare providers without worrying about whether they are in network. All a patient would have to do is go to a doctor and show an insurance card. There would be “no more copays, no more deductions, and no more fighting with insurance companies when they fail to pay for charges.”

Opponents say the single-payer system is cost prohibitive. It would result in higher taxes and cut payments to hospitals and doctors by as much as 40 percent. The plan calls for hospitals and doctors to be paid at Medicare rates, which are reduced from private insurance rates. Even Sen. Sanders admits that “there will be pain” if the nation adopts the system he favors. On the presidential campaign trail in 2016, he said the plan would cost $1.4 trillion per year. To pay for it, he called for a new 2.2 percent income tax, a 6.2 percent tax on employers, and higher taxes on the wealthy. An independent analysis of Sen. Sanders’ plan, conducted by the left-leaning Urban Institute, estimated that it would cost $32 trillion in projected government expenditures over 10 years. Critics also say that single-payer systems would ration care and force patients to wait for treatment.

To put this in perspective, the United States can barely afford its existing healthcare obligations. In 2017, the federal government spent more than $700 billion on Medicare—a 65 percent increase over the past 10 years. Annual costs per capita are expected to increase by 4.6 percent over the next decade. The latest Medicare Trustees report, released in June, reported that the Part A Trust Fund, which covers payment for hospital care, will be depleted in 2026—three years earlier than previously projected.

On the other hand, Matt Brueing, of the People’s Policy Project, notes that one key selling point of a single-payer system is that it spares physicians the reams of paperwork they have to contend with under the current private insurance system. He says that U.S. physicians could reduce their administrative time to Canadian levels and that healthcare spending would fall by more than 11 percent.

Other experts, however, such as Deane Waldman, MD, MBA, a retired pediatric cardiologist and director of the Center for Health Care Policy at the nonprofit Texas Public Policy Foundation, say the likely cuts to provider rates mean “physicians would be paid a salary they simply will not and frankly cannot afford to accept—not with medical student loans averaging more than $183,000 at graduation and 60 to 70 percent overhead costs for a primary care doctor’s office. Doctors will simply retire or find more remunerative, nonclinical work in research or administration.”

Julia Williams is a senior manager in the AAOS OGR.