When people argue about Medicare for All, they are often arguing about different things. Supporters picture one system. Opponents describe another. Politicians invoke the phrase without specifying what they mean by it. Commentators treat it as an abstraction.
There is an actual bill. It was introduced in the United States Senate on April 29, 2025, by Senator Bernie Sanders, with sixteen co-sponsors, as S. 1506 — the Medicare for All Act. A companion bill, H.R. 3069, was introduced simultaneously in the House by Representatives Pramila Jayapal and Debbie Dingell, with 104 original co-sponsors.
This article documents what that legislation actually contains. Not what supporters claim it would accomplish. Not what opponents warn it would destroy. What the bill text says, what the financing proposals involve, and where the legislation is specific versus where it leaves questions to implementation. Readers who want the broader evidence on costs, international models, and political obstacles will find that in the main series. This piece answers a narrower question: what exactly are we talking about?
Who Is Covered and How Enrollment Works
The bill’s coverage provision is unambiguous. Every individual who is a resident of the United States is entitled to benefits. The bill directs the Secretary of Health and Human Services to establish criteria for determining residency. It also authorizes the Secretary to extend eligibility to other individuals not covered by the residency definition in order to ensure that every person in the United States has access to care, while separately requiring a rule to prevent individuals from traveling to the United States solely to obtain benefits.
Enrollment is automatic. The bill requires a mechanism for automatic enrollment at the time of birth in the United States, or upon the establishment of residency. There is no application process. No open enrollment window. No employer action required. A Medicare for All card is issued in conjunction with enrollment — the bill explicitly prohibits the card from containing a Social Security number.
The bill includes a non-discrimination provision covering race, color, national origin, age, disability, marital status, citizenship status, primary language, genetic conditions, previous or existing medical conditions, religion, sex, gender identity, sexual orientation, and pregnancy and related medical conditions, including termination of pregnancy. Individuals who believe they have been discriminated against can file administrative complaints or sue in federal district court; damages available include compensatory and punitive damages, injunctive relief, and attorneys’ fees.
What the Program Covers
The coverage package is comprehensive. The bill lists seventeen categories of covered benefits, provided they are medically necessary or appropriate for the maintenance of health or for the diagnosis, treatment, or rehabilitation of a health condition:
Hospital services — including inpatient and outpatient care, 24-hour emergency services, and inpatient prescription drugs.
Ambulatory patient services — outpatient care in physician offices, clinics, and surgery centers.
Primary and preventive services — including chronic disease management.
Prescription drugs and medical devices — including outpatient prescription drugs, biological products, medical devices, and all contraceptive items approved by the FDA.
Mental health and substance use treatment — including inpatient care and treatment for co-occurring mental illness and substance use disorders. The bill does not impose a separate cost-sharing structure for behavioral health, which current law’s mental health parity requirement has frequently failed to enforce in practice.
Laboratory and diagnostic services.
Comprehensive reproductive care — including abortion, contraception, and assistive reproductive technology.
Comprehensive maternity and newborn care.
Comprehensive gender-affirming health care.
Oral health, audiology, and vision services — dental, hearing, and vision coverage, which current Medicare excludes or covers only minimally.
Rehabilitative and habilitative services, including devices.
Emergency services, including transportation.
Pediatrics — including early and periodic screening, diagnostic, and treatment services.
Necessary transportation to receive healthcare items and services for persons with disabilities, older individuals with functional limitations, and low-income individuals.
Licensed marriage and family therapists and licensed mental health counselors — provider types not consistently covered under current commercial insurance.
Home and community-based long-term care services and supports — including personal care, self-directed services, and home and community-based attendant services. This is one of the most significant expansions relative to current Medicare, which covers only limited home health and does not cover custodial long-term care.
Telehealth — any item or service in the above categories, to the extent practicable.
The Secretary is required to evaluate at least annually whether the benefits package should be improved based on changes in medical practice, new research findings, or other developments in health science, and to make recommendations to Congress. Individual states may also provide additional benefits to residents beyond the federal package, at state expense.
Cost-Sharing: What Patients Pay at the Point of Care
The bill’s position on cost-sharing is direct. No deductibles. No coinsurance. No copayments. No similar charges. The bill prohibits balance billing — no provider participating in the program may charge an individual anything beyond what the program pays.
One limited exception applies to prescription drugs. The bill authorizes the Secretary to establish a cost-sharing schedule for outpatient prescription drugs, subject to specific constraints: the schedule must be evidence-based and patient-centered; it must encourage the use of generics; it cannot apply to preventive drugs; it cannot exceed $200 annually per individual (adjusted for inflation); and it cannot be imposed at all on individuals with household income at or below 250 percent of the federal poverty line. The Secretary also has authority to exempt brand-name drugs from the out-of-pocket calculation when a safe and appropriate generic alternative exists.
That prescription drug exception is the bill’s only cost-sharing mechanism. Everything else — hospital stays, surgery, physician visits, emergency care, dental, vision, mental health treatment, long-term care services — carries no patient cost at the point of care.
The Transition: How Existing Programs Are Phased In
The bill does not flip a switch. It establishes a transition period with immediate improvements to existing programs followed by a phase-in of full universal coverage.
Immediate improvements to current Medicare take effect in the first year after enactment: out-of-pocket cost protections for existing Medicare fee-for-service beneficiaries; reduction of the Medicare Part D annual out-of-pocket threshold; expansion of Medicare Part B to cover dental services, vision services, and hearing aids; and elimination of the 24-month waiting period that currently makes people with disabilities wait two years after qualifying for Social Security Disability Insurance before they can access Medicare.
Children under 19 are enrolled in the program in the first calendar year after enactment — the fastest phase-in category.
A Medicare buy-in option and a public option become available during the transition period, lowering the Medicare eligibility age as a bridge to universal enrollment.
Full universal coverage — every resident enrolled in the Medicare for All Program — takes effect on January 1 of the fourth calendar year after enactment. Based on a 2025 enactment date, that would be January 1, 2029.
During the transition, existing Medicare, Medicaid, CHIP, and other federal health programs continue operating. The bill sunsets the ACA’s federal and state exchanges once universal coverage takes effect. The VA health system relationship is addressed separately — veterans can access any provider under the universal program while the VA system continues to exist.
Private insurance for covered services is prohibited beginning on the date full benefits take effect. The bill is explicit: it shall be unlawful for a private health insurer to sell coverage that duplicates the benefits provided under the Medicare for All Program. Supplemental insurance for services not covered by the program — cosmetic procedures, for example — remains permitted. The employer-based insurance system as it currently functions would cease to exist for covered services.
How Providers Are Paid
The bill establishes two payment mechanisms depending on provider type.
Institutional providers — hospitals, skilled nursing facilities, independent dialysis facilities — are paid through global budgets. At the beginning of each fiscal quarter, the Secretary negotiates and pays a prospective budget to cover all operating expenses for items and services provided during that quarter. This is a significant structural departure from the current fee-for-service billing model, which requires hospitals to submit individual claims for every service rendered to every patient across dozens of payers. Under a global budget, a hospital receives quarterly operating funds and is responsible for managing care within that budget. Capital expenditures — construction, major equipment — are handled through separate negotiation rather than built into operating payments.
Individual providers — physicians and other practitioners — are paid through fee-for-service using the Medicare physician fee schedule. The bill includes a specific provision directing the Secretary to ensure accurate valuation of services under that fee schedule. This addresses a documented problem in current Medicare: the fee schedule has systematically undervalued primary care and cognitive services relative to procedures and specialty care, distorting provider incentives over decades. The bill does not specify what that revaluation looks like in practice; it mandates that HHS address it.
Prescription drug prices are negotiated directly by the Secretary of Health and Human Services, who is also required to establish a formulary. The bill directs HHS to negotiate prices — the monopsony purchasing power that every other wealthy country uses to pay prices substantially lower than the United States currently pays. Current law prohibits Medicare from negotiating drug prices directly; the Inflation Reduction Act of 2022 created a limited negotiation authority for a small number of drugs; this bill establishes comprehensive negotiation authority across the program.
What the bill does not fully resolve: The legislation does not specify the level at which physician fee schedule rates would be set relative to current commercial insurance rates. Current Medicare rates are substantially lower than commercial rates for many services — this gap is a documented concern among provider groups and a legitimate open question in the policy debate. The bill mandates accurate valuation and directs HHS to develop payment rates through a consultative process with providers, but the specific rates would be determined through rulemaking after enactment. This is the largest unresolved question in the bill’s payment structure, and it is worth naming directly: the legislation creates the architecture for provider payment but leaves the rates themselves to implementation.
The Workforce Transition Fund
Approximately 500,000 people work in the administration of the private health insurance system — processing claims, managing prior authorizations, handling billing, operating call centers. Their jobs would not exist under a single standardized payer. The bill addresses this directly.
Section 602 of the bill establishes a worker assistance program. For up to five years following the date on which full benefits take effect, at least one percent of the national health budget must be allocated to programs providing assistance to workers who perform functions in the administration of the health insurance system, or related functions within health care institutions, who experience economic dislocation as a result of the implementation of the act.
The bill specifies what that assistance includes: wage replacement, retirement benefits, job training and placement, preferential hiring in the new program’s administrative infrastructure, and education benefits.
One percent of the national health budget is a substantial figure. Total national health expenditure in the United States exceeded $5 trillion in 2024. One percent of even a substantially reduced post-reform budget would represent tens of billions of dollars over the five-year transition window. The bill’s worker assistance provision is not a footnote — it is a legislated commitment to a defined category of affected workers with a funding floor attached.
Financing: What Sanders Has Proposed
The bill text itself establishes a Medicare for All Trust Fund and directs that it be funded through appropriations — it does not specify the tax mechanisms. The financing proposals come from Senator Sanders’s accompanying legislative documents and analysis by the RAND Corporation and the Political Economy Research Institute (PERI) at the University of Massachusetts.
Sanders’s proposed financing package includes four primary revenue sources:
A 4% income-based premium on household income above a filing threshold. Families at or below the federal poverty line pay nothing. For a family of four earning $50,000, the annual premium would be approximately $844 — compared to the current average worker contribution of $6,850 toward employer-sponsored family coverage (KFF Employer Health Benefits Survey 2025).
A 7.5% employer payroll tax replacing current employer premium contributions. The payroll tax applies to wages above $2 million in total payroll. For most employers — particularly large employers currently paying $17,000 or more per employee per year toward insurance — this represents a cost reduction. Small businesses, which currently pay higher per-employee premiums with worse coverage because they lack negotiating power, would benefit most dramatically from the conversion.
Progressive income tax increases on household income above $250,000, with rates scaling upward at higher income levels.
Capital gains and wealth taxes on the top 0.1 percent of households.
The RAND Corporation and JAMA analysis of Medicare for All financing found that the distributional effect of this structure would be a significant shift from the current regressive system. Today, flat premiums as a share of income are more burdensome on lower-income households. Under the proposed financing, the lowest-income households would see their healthcare burden fall from approximately 27% to 15% of total compensation. The highest-income households would see theirs rise from approximately 27% to 31%.
Citizens for Tax Justice analysis found that middle-class families would see after-tax income increase by approximately $3,240 per year under Medicare for All, primarily because the premium and out-of-pocket savings exceed the tax increases for households in the middle of the income distribution.
These financing proposals are not in the bill text. They represent Sanders’s stated approach to funding the program and would be enacted through separate tax legislation. A reader evaluating the full policy proposal needs to understand that the bill creates the program structure while the financing question — substantial and contested — is treated as a parallel legislative track.
What Happens to Existing Federal Programs
The bill’s relationship to existing federal health programs is addressed in Title IX:
Medicare — The existing Medicare program integrates into the Medicare for All Program. Traditional Medicare fee-for-service and Medicare Advantage would both be absorbed into the universal program. The Medicare Advantage program — currently the vehicle through which private insurers administer Medicare for approximately 33 million enrollees and generate the $84 billion annual overpayment documented by MedPAC — would cease to exist as a separate program.
Medicaid — The core Medicaid program is subsumed into Medicare for All for covered services. The bill maintains a separate state role for institutional long-term care services — nursing facility care, intermediate care facilities, inpatient psychiatric services — which remain under state Medicaid plans with federal matching, subject to maintenance-of-effort requirements that prevent states from reducing eligibility standards below their 2025 levels.
CHIP — The Children’s Health Insurance Program is superseded by the universal enrollment of all children under 19 in the first year.
ACA exchanges — The federal and state insurance exchanges sunset once full benefits take effect.
ERISA continuation coverage (COBRA) — The bill repeals COBRA continuation coverage requirements, which currently require employers to offer terminated employees the option to continue employer-sponsored coverage at full cost — averaging approximately $2,200 per month for family coverage. COBRA becomes unnecessary when coverage is universal and continuous regardless of employment status.
TRICARE — Military dependents and retirees covered under TRICARE would move into the universal program. Active duty military medical care is separately administered and not addressed by this bill.
VA health system — The VA is addressed in the conforming amendments section. Veterans enrolled in VA care would be entitled to benefits under the Medicare for All Program and could receive care from any licensed provider, not only VA facilities. The VA health system itself would continue to exist; the bill does not eliminate it.
What the Bill Is and What It Isn’t
Several common characterizations of this legislation are imprecise in ways that matter for evaluating it.
This is not socialized medicine. Socialized medicine means the government both finances and delivers healthcare — employing physicians, owning hospitals. Under the Medicare for All Act, physicians remain in private practice. Hospitals remain largely privately owned and operated. Pharmaceutical companies remain private. The government pays the bills. This is the same structural relationship as current Medicare — a publicly financed program with privately delivered care — extended universally.
This would not eliminate the healthcare industry. It would eliminate private health insurance for covered services. Physicians, hospitals, pharmaceutical companies, medical device manufacturers, home health agencies, and every other provider of actual healthcare services would continue to operate. The administrative apparatus of private insurance claims processing, prior authorization management, and multi-payer billing would be substantially reduced.
The financing is not in the bill. The bill creates the program. The tax proposals are separate. Evaluating the fiscal impact of Medicare for All requires engaging both the program structure and the financing proposals together — treating one without the other produces an incomplete picture in either direction.
Provider payment rates are not fully resolved. The bill establishes the payment mechanisms — global budgets for hospitals, fee-for-service for physicians, direct negotiation for drugs — but the specific rate levels would be determined through a regulatory process after enactment. How those rates compare to current commercial rates, and what effect that would have on provider behavior and workforce, is a significant open question that the bill’s text does not answer.
The transition takes four years. Full universal coverage does not take effect immediately. The bill includes a structured phase-in beginning with children and existing Medicare improvements, with full universal enrollment at the start of the fourth year after enactment.
The Scope of What Would Change
If enacted as written, the Medicare for All Act would be the largest single reorganization of the American healthcare financing system in the country’s history — larger than the creation of Medicare and Medicaid in 1965, larger than the Affordable Care Act in 2010.
Every American resident would have continuous, automatic coverage for a comprehensive benefit package with no cost-sharing at the point of care. The current system of employer-sponsored insurance, individual market insurance, Medicaid, Medicare, CHIP, and the uninsured would be replaced by a single universal program. The administrative complexity of billing across hundreds of payers with different forms, codes, and requirements would be replaced by a single standardized system. Drug prices would be subject to direct government negotiation. The industries whose revenue depends on the current multi-payer architecture — primarily private health insurers — would be eliminated as participants in the coverage market for covered services.
Whether this transformation is desirable, feasible, or politically achievable is a separate set of questions that the evidence across this series addresses in detail. This article is about what the bill actually says. On that narrower question, the legislation is specific about coverage and enrollment, explicit about cost-sharing, clear about the transition timeline, direct about the workforce assistance commitment, and deliberately silent on the provider rate levels and financing mechanisms that would determine much of the system’s real-world operation.
Reading the bill is not the same as resolving the policy debate. But it is a necessary precondition for having it honestly.
The full text of the Senate bill (S. 1506) is available at sanders.senate.gov. The House bill (H.R. 3069) is available at congress.gov. This article cites the Senate bill text directly; where the House and Senate bills differ in structure, those differences are noted.
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