Free Health Care: What It Actually Costs

No deductible. No copay. Nothing owed at the doctor’s office. Two socialist platforms now promise health care for everyone at no cost to the patient. Neither says what that promise would cost the country and taxpayers, or what patients would give up to get it.

The Democratic Socialists of America and the Party for Socialism and Liberation both call for universal health care, but neither names a price, an eligibility rule, or a benefit package. A bill in Congress fills in those blanks: the Medicare for All Act of 2025. It has the backing of socialist members of Congress, so it is used here to price these programs.

That bill would require between $2.1 trillion and $4.1 trillion a year in new federal outlays. The best single estimate is $3.0 trillion.

That $3.0 trillion is the most expensive of five single payer designs CBO priced, the cheapest of which came to $1.5 trillion a year. What separates them is what doctors get paid, what patients pay, and whether long-term care is covered. The bill settles two of the three.

It eliminates deductibles and copayments and covers long-term care, the features that most increase federal spending. That spending would have to be paid for through higher taxes, more deficit spending, or public ownership of the largest corporations, which the DSA platform also calls for.

Supporters of the socialist health care programs point to a Yale study finding that single payer would cut the country’s total health bill by about $1 trillion a year. The study is a prepublication version and has not been peer reviewed. Even taken at face value, it still means a large federal increase.

The reason is who pays. Today the federal government pays about $1.7 trillion of a $5.3 trillion total; employers, insurers, and families pay the rest. Under single payer, the federal government pays the whole bill. Its costs go way up.

If the total falls to $4.3 trillion, that is still about $2.6 trillion a year in new federal spending, using the published numbers most favorable to the socialist proposals.

The other cost to Americans is choice. Under the bill, one federal agency would pay every hospital and doctor in the country and set what each is paid. Today, if your employer switches plans or your doctor leaves a network, you can look for another plan. The bill makes it unlawful for an insurer to sell coverage that duplicates what the program covers, so there would be no other plan to move to.

Patients could still choose among authorized providers, as long as those providers stay private. The DSA program also commits to investing in new public hospitals and clinics, which would make the government the provider as well as the payer. Where the government already is the provider, as in the Department of Veterans Affairs and the military health system, patients are generally assigned a primary care team and specialists rather than picking their own doctors.

Most Americans say the care and coverage they have now work for them, even while they fault the system as a whole. Gallup finds 71 percent rate the care they receive as excellent or good and 65 percent say the same of their own coverage. Yet 70 percent say the system is in crisis. The coverage most of them rate well is the coverage the bill would replace.

Three points favor the single payer proposal. CBO finds the country’s total health bill could fall by as much as $0.7 trillion a year. The United States trails other wealthy countries on life expectancy and preventable deaths while spending nearly two and a half times as much per person. And universal coverage works elsewhere. The three health systems the Commonwealth Fund ranks highest in the world all have it.

Three points argue against it. CBO’s same range allows that the total bill could instead rise by $0.3 trillion, and CBO projects longer waits and more forgone care under the design Congress has proposed. Canada, the closest comparison, reports a median wait of 28.6 weeks from referral to treatment, more than half a year, up from 9.3 weeks in 1993. And much of America’s shorter life expectancy comes from causes other than who pays for health care, such as overdoses, guns, car crashes, and obesity.

The Commonwealth Fund ranking also cuts against the bill’s design. Of its top three systems, only the United Kingdom’s is single payer. The other two rely on private insurance, which the bill would prohibit. What the best systems share is universal coverage, not a single government payer.

Care at no cost to the patient still comes with a bill. The legislation that would deliver it moves a sixth of the American economy into one federal agency and adds about $3 trillion a year in new federal spending. Patients would also pay in longer waits and in a plan they could not leave. The platforms promising free care leave that part out.