Same goal. Different path.
We don't leave the safety of a bridge to chance. Why do we govern healthcare like ordinary commerce?
Healthcare as Infrastructure is a third path for American healthcare. It is not a government takeover, and it is not business as usual. It is a better way to govern the system we already have.
Understanding the alternatives
First, a fair description
"Medicare for All" usually refers to a single-payer system. One public health plan, run by the federal government, would cover every resident. Private insurance for the same services would largely disappear, and the plan would be paid for through taxes rather than premiums and deductibles.
Its supporters are responding to real problems: people losing coverage when they lose a job, families buried in medical debt, and patients denied care they were told was covered. Those concerns are legitimate. We share them.
Where we differ is not the destination. It is the route, and what has to be torn down to get there.
Two approaches, shared concerns
How the two approaches compare
| Question | Medicare for All | Healthcare as Infrastructure |
|---|---|---|
| The goal | Universal coverage | Universal, reliable access |
| Who pays for care? | One government plan, funded by taxes | A regulated mix of public programs, employers, and private insurers |
| What happens to private insurance? | Largely eliminated for covered services | Kept, but regulated so insurers can't profit by denying necessary care |
| Role of government | Runs the insurance plan | Sets and enforces the rules of the road |
| Hospitals and doctors | Stay mostly private, paid by the single plan | Stay private, competing within public guardrails |
| Who decides your treatment? | You and your doctor, under the public plan's rules | You and your doctor, guided by evidence-based clinical standards |
| What changes first? | How healthcare is financed | How healthcare is classified and governed |
| Scale of change | Replace the current system | Realign the institutions we already have |
| Real-world examples | Canada and Taiwan (single-payer insurance) | The Netherlands, Switzerland, and Germany (regulated private and nonprofit insurers) |
The goal
Medicare for All
Universal coverage
Healthcare as Infrastructure
Universal, reliable access
Who pays for care?
Medicare for All
One government plan, funded by taxes
Healthcare as Infrastructure
A regulated mix of public programs, employers, and private insurers
What happens to private insurance?
Medicare for All
Largely eliminated for covered services
Healthcare as Infrastructure
Kept, but regulated so insurers can't profit by denying necessary care
Role of government
Medicare for All
Runs the insurance plan
Healthcare as Infrastructure
Sets and enforces the rules of the road
Hospitals and doctors
Medicare for All
Stay mostly private, paid by the single plan
Healthcare as Infrastructure
Stay private, competing within public guardrails
Who decides your treatment?
Medicare for All
You and your doctor, under the public plan's rules
Healthcare as Infrastructure
You and your doctor, guided by evidence-based clinical standards
What changes first?
Medicare for All
How healthcare is financed
Healthcare as Infrastructure
How healthcare is classified and governed
Scale of change
Medicare for All
Replace the current system
Healthcare as Infrastructure
Realign the institutions we already have
Real-world examples
Medicare for All
Canada and Taiwan (single-payer insurance)
Healthcare as Infrastructure
The Netherlands, Switzerland, and Germany (regulated private and nonprofit insurers)
We didn't say: adopt single payer, eliminate private insurance, nationalize hospitals, deregulate everything, or create a new bureaucracy. It's not a replacement blueprint. It's an alignment blueprint.Healthcare as Infrastructure
A personal note from Sheri
I used to think single payer was the only answer
For years, I assumed the only real alternative to our system was single payer, the Canadian model. If you wanted everyone covered, I thought, the government had to run the insurance.
Then I spent years on the front lines as a surgeon and physician advisor, watching how decisions about care actually get made. I also began studying how other wealthy, capitalist countries cover everyone.
What I found surprised me.
Many of the countries that outperform us didn't abandon private insurance or free markets. What they share is something more basic. They decided healthcare is infrastructure, and they govern it that way.
Insurers still compete. Hospitals still innovate. But the rules make sure the system serves patients first.
That changed how I saw our own problem. The trouble isn't that America has private insurers. It's that we govern healthcare like ordinary commerce, and then act surprised when it behaves like ordinary commerce.
Sheri A. Mancini
MD, FACS
THE GLOBAL PERSPECTIVE
Single payer is one road to universal coverage. It isn't the only one.
Every wealthy nation that covers everyone made a choice about how to do it. Some run the hospitals themselves. Some use one public insurer. Others keep many private or nonprofit insurers, but hold them to strict public rules.
Government-run care
UNITED KINGDOM
Government owns most hospitals and employs many clinicians.
Single payer
CANADA, TAIWAN
One public insurer pays for care; doctors stay private.
Closest to Medicare for All
Social insurance
GERMANY, JAPAN
Regulated, mostly nonprofit insurance funds; private care.
Regulated market
NETHERLANDS, SWITZERLAND
Private insurers must accept everyone under strict public rules.
Closest to Healthcare as Infrastructure
Four roads to universal coverage, from government-run to regulated market
The United States already uses pieces of every model. The VA is government-run care. Traditional Medicare works like single payer. Employer plans resemble social insurance. Tens of millions of people have no coverage at all. What we lack is not a model. It is a shared governing principle that ties the pieces together.
CLASSIFICATION FIRST, FINANCING SECOND
A note to Medicare for All supporters
If you support Medicare for All, we are not on opposite sides. We agree that the current system fails too many people. The question is what comes first.
Changing who pays doesn't automatically change how the system behaves. The Affordable Care Act expanded coverage to millions, but it left healthcare governed as ordinary commerce. Carve-outs, loopholes, and industry influence followed. Even within Medicare today, private Medicare Advantage plans use prior authorization in ways that frustrate patients and physicians alike. A financing label alone does not guarantee good governance.
That is why Healthcare as Infrastructure starts one step earlier. First, classify healthcare as the essential infrastructure it is. Then build the guardrails, transparency, and accountability that every financing model needs. Whatever path the country eventually chooses, it will work better on that foundation.
Governance is incentive design in service of constitutional purpose.
CLASSIFICATION FIRST, FINANCING SECOND
A note to Medicare for All supporters
If you support Medicare for All, we are not on opposite sides. We agree that the current system fails too many people. The question is what comes first.
Changing who pays doesn't automatically change how the system behaves. The Affordable Care Act expanded coverage to millions, but it left healthcare governed as ordinary commerce. Carve-outs, loopholes, and industry influence followed. Even within Medicare today, private Medicare Advantage plans use prior authorization in ways that frustrate patients and physicians alike. A financing label alone does not guarantee good governance.
That is why Healthcare as Infrastructure starts one step earlier. First, classify healthcare as the essential infrastructure it is. Then build the guardrails, transparency, and accountability that every financing model needs. Whatever path the country eventually chooses, it will work better on that foundation.
Governance is incentive design in service of constitutional purpose.