An aide in Mr. Sanders’s Senate office said the list was deliberately broad.
It’s easy to see how cosmetic surgery might fall outside this list. But several experts strained to come up with other examples. “You have to really rack your brains to think of anything that would not be covered,” said Cynthia Cox, a vice president at the Kaiser Family Foundation, a health research group.
Ms. Cox consulted several of her colleagues, and came up with a few ideas. The bill might leave room for private insurance for nursing home care, similar to existing markets for long-term care insurance. It might allow people to buy disability insurance to replace lost income, but not related medical treatment. And then there were the things like cosmetic surgery: services that would not be considered “medically necessary” under Medicare for all but that some people might want. She called these categories of care “loopholes,” and said it was tough to imagine private companies wanting to offer such products.
It is true that most other countries that have single-payer systems also have some supplemental role for private insurance. But those countries have systems that are different in key ways from the current Medicare for all proposal. In some countries, individuals are expected to pay deductibles or co-payments toward their treatment, and private companies offer insurance to fill those financial gaps in coverage. In others, certain benefits are left out, and private companies then offer coverage for, say, prescription drugs.
You might think that Democratic politicians who endorse the Sanders plan would embrace the bill’s comprehensiveness as a virtue. And, in some ways, they do. But some also appear nervous about saying that they will do away with an entire industry. Public opinion surveys suggest that voters are skeptical about plans that will take away their private coverage. Some co-sponsors of Mr. Sanders’s bill now say they are more comfortable with optional plans that would not bar duplicate coverage. Some others have embraced the “supplemental coverage” line.
“In order to create a role for private insurance in any of those ways, you need to weaken the main system,” said Adam Gaffney, the president of Physicians for a National Health Program, which supports a very broad single-payer plan along the lines of Mr. Sanders’s bill. He said the effective abolition of private insurance was a strength of the proposal, which doesn’t require insurance for financial or benefit gaps.
If Medicare for all became law, it is entirely possible that legislative negotiating would make the plan less broad and carve out such a complementary role for private industry.
But the Sanders plan was written to avoid such holes. It doesn’t have any deductibles or co-payments. It covers a very wide array of medical benefits. And that is why politicians are likely to keep employing their own sort of loophole, by pointing to insurance markets that may not exist.