Medicare For All? Proceed With Caution — Why Current Medicare Models Aren't Ready to Scale

Medicare for All is regaining political momentum, championed by high-profile advocates and winning primary contests. The moral case for universal coverage is powerful: no one should forgo care because they cannot afford it, and health security should not depend on your employer, ZIP code, or luck.

I've spent my career inside the Medicare ecosystem—at CMS, helping stand up the Innovation Center, caring for veterans, and now leading an organization that operates Medicare Advantage plans. Those experiences have strengthened my commitment to universal coverage and taught me a cautionary lesson: neither of the Medicare models we use today is ready to become the default system for roughly 330 million people.

Main Argument

Traditional Medicare and Medicare Advantage (MA) each have strengths and demonstrable weaknesses. Scaling either program nationally without redesign would scale those weaknesses too. Advocates who invoke the Medicare brand need to be explicit: which elements of the program do they mean to expand—the coverage guarantee, the payment architecture that shaped today’s delivery system, or both?

Problems With Traditional Medicare

• Affordability Gaps: Traditional Medicare is not "free." Beneficiaries face Part B and Part D premiums, no universal annual cap on out-of-pocket spending, and often pay for Medigap premiums or choose plans that add cost. For many seniors on fixed incomes, those expenses are unaffordable.
• Missing Essential Benefits: Routine dental, vision, and meaningful hearing coverage are largely excluded. These are not luxuries: untreated hearing and dental problems drive isolation, depression, falls, infection, malnutrition, increased hospitalizations, and long-term decline.
• Procedural Payment Bias: Medicare's fee schedule rewards procedures far more generously than cognitive and preventive care. Because commercial insurers benchmark to Medicare, those incentives propagate across the health system, shaping specialty choice, capacity, and medical education.
• Slow Benefit Modernization: Benefit design is controlled by Congress, and updating coverage can require decade-long political fights. A universal system that needs legislation to evolve risks falling behind medicine.

Problems With Medicare Advantage

• Demonstrates Possibilities—and Risks: MA can cap out-of-pocket costs and deliver dental, vision, hearing, transportation, and social supports. Capitation can align incentives toward prevention.
• Gaming and Perverse Incentives: Risk-adjustment systems intended to pay for sicker members have at times incentivized aggressive coding detached from care. Supplemental benefits can prioritize enrollment appeal over long-term clinical value.
• Administrative Burdens: Prior authorization applied at scale often becomes a tax on care, disproportionately burdening patients least able to navigate appeals. Star Ratings can be gamed or treated as a scoreboard rather than a diagnostic tool; litigation has increasingly replaced internal quality improvement.

Why Payment Architecture Matters

Coverage is only one half of a health system. The way we pay for care shapes what care is produced. Fee-for-service rewards volume; capitation can reward denial if poorly governed. Any serious plan for national coverage must state how providers will be paid, how budgets or prices will be set, and what will prevent perverse behavior.

What A Responsible Transition Would Require

• Be explicit about the payment model: If fee-for-service remains, what curbs overuse? If capitation or global budgets are used, who bears risk and how is care protected from denial?
• Define a flexible, modern benefit package that includes dental, vision, and hearing and can be updated without decade-long legislation.
• Fix risk adjustment so it rewards caring for complex patients rather than rewarding documentation.
• Rebuild quality measurement around pivotal events (first fall, new serious diagnosis, transition to hospice) rather than administrative metrics that are easy to game.
• Constrain abusive prior authorization and align incentives to reduce administrative barriers to timely care.
• Be transparent about financing: account for employer contributions, household spending, existing subsidies, provider payment changes, and administrative costs.
• Address enrollment dynamics so plans can invest in long-term outcomes (reexamine annual automatic churn and short enrollment horizons).

Practical Reforms I Support

• Standardize core benefits across plans so competition focuses on outcomes rather than gimmicks.
• Redesign quality metrics to capture moments that determine an older person's trajectory.
• Fix risk adjustment and auditing so documentation reflects genuine clinical need.
• Limit harmful prior authorization practices and increase oversight of utilization management.
• Consider enrollment reforms that encourage multi-year planning and investments in prevention.

These changes would cost parts of the private industry money and might reduce current competitive advantages. I would accept that trade to build a system that actually protects people.

Conclusion

The moral argument for universal coverage is compelling and correct. But moral clarity is not a substitute for technical rigor. Advocates for Medicare for All should publish concrete blueprints that answer the practical questions above: payment design, benefit evolution, oversight, and financing. Universal coverage deserves more than a slogan—it deserves a detailed plan built in public.

Universal coverage is the destination; the vehicle matters. Choose the vehicle deliberately.