TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross. At Democratic presidential debates this year, candidates have clashed over health care and specifically over the idea of "Medicare for All."

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BERNIE SANDERS: I - who wrote the damn bill, if I may say so - intend to eliminate all out-of-pocket expenses, all deductibles.

JOE BIDEN: And if you notice, nobody's yet said how much it's going to cost the taxpayer. I hear this - large savings...

ELIZABETH WARREN: Costs are going to go up for giant corporations, but for hard-working families across this country, costs are going to go down. And that's how it should work under Medicare For All in our health care system.

GEORGE STEPHANOPOULOS: Senator Sanders, you were involved...

GROSS: For some perspective on just how a Medicare for All is defined by the candidates - how it would work, what it would cost - we turn to Sarah Kliff, an investigative reporter for The New York Times. She's covered health care policy for the past decade for The Washington Post and Vox and, since June, for The New York Times. She spoke with FRESH AIR's Dave Davies.

DAVE DAVIES, BYLINE: Well, Sarah Kliff, welcome back to FRESH AIR. You know, when people hear the term Medicare for All, I wonder if we're all hearing different things. I mean, does it mean literally enrolling everyone in the current Medicare program, or is it sort of a generic term for a single-payer, government-sponsored universal health care?

SARAH KLIFF: I think it is more of the latter at this point. I think Medicare for All has been thrown around so much in the political debate. It essentially means, when politicians say it, a very generous health care plan for all Americans that they will call Medicare. It's quite different, actually, from the Medicare system that covers seniors right now. It would have many more benefits than what seniors are currently enrolled in. But it's become this catchall, and you see variations like Medicare for all who want it or Medicare for all who want to sign up. It's become - it polls very well. People like the idea of giving everyone Medicare. But it's become this catchall phrase for a very generous set of government health insurance plans.

DAVIES: Right. Well, let's talk just a little bit about the Medicare plan that currently exists for senior citizens. A lot of people assume that it's free government insurance - not really, right?

KLIFF: No. No, it's not. Medicare's a pretty complicated health insurance plan. It has three different parts - Part A for hospitals, Part B for doctors and D for drugs. And different parts come with premiums. They come with the co-payments that you might be used to from your private insurance. There are deductibles. Many seniors buy private supplemental plans to cover all those costs that you have to pay out of pocket when you're a Medicare enrollee, and there's certain benefits that are not covered. So it is a program that does require seniors to pay a significant amount, and you do see some cases, particularly with prescription drugs, where seniors on Medicare are still struggling to afford the medications that they need.

DAVIES: Right. And part of what you pay is for supplemental insurance for a private insurer, but you can also pay - I guess the minimum is $135 - for the doctor's part of the coverage to the government, right? And that goes up with income.

KLIFF: It does go up with income, and that's a premium you're going to be paying month after month. It's quite similar to the way we pay premiums when we are privately insured. Now, I think if you hear that number - right? - 135, that's significantly less than one would pay for private insurance. The hospital part, Part A, does not have a premium. So it is a relatively good deal compared to the private market. Seniors do really like it. Medicare gets high marks year after year. But it certainly does come with some costs, and those costs can be a struggle for some seniors to afford.

DAVIES: Right. And for people who are more affluent, it's not 135. It can be substantially more. So there are costs.

KLIFF: Yes. Yes, there are definitely - seniors, you know, they get to 65. They've earned their way into this Medicare program, but they're still expected to keep chipping in some percentage of the costs that they're accruing through it.

DAVIES: Right. Now, Senator Bernie Sanders, who, of course, is a candidate for president - I mean, he proposes Medicare for All as a campaign proposition, and he has a bill in Congress. It would be different from Medicare, right? It would be far more generous.

KLIFF: It would be far, far more generous. What Bernie Sanders envisions is a health care plan that has no co-payments, no premiums, no deductibles. You don't pay a single penny when you go to the doctor, when you pick up your prescriptions. So that is very, very different from the current Medicare system. It's also a much wider range of health care benefits. Things like glasses and dental, prescription drugs - those are all worked into the basket of benefits that Senator Sanders wants to cover. So it is a quite more robust - more generous than our Medicare program, more generous than most other countries' single-payer systems. That's really the plan that Bernie Sanders is talking about when he talks about Medicare for All.

DAVIES: Right. And it's truly free to those who are in it, and I guess that's consistent with the notion that health care is a right. It shouldn't depend on your ability to pay.

KLIFF: Yeah. This is something, you know, I've talked to Senator Sanders about. And something I know he feels quite strongly about is the idea that no one should think about money when they're going to the doctor. You see other countries that have single-payer systems but also ask patients to make small co-pays when they go to the doctor - maybe five, 10, $20. Senator Sanders feels very strongly that that should not happen. He doesn't want anyone weighing - is this doctor visit worth $5 to me or not? So the system he's outlined, the system that a number of his other competitors in the presidential primary have endorsed, is one where you do not pay anything when you go to the doctor. The entire system is financed by tax revenue. It is not financed by co-payments, deductibles or premiums.

DAVIES: And I think a lot of people would think, well, that's exactly what, you know, exists in other industrialized countries. Is it?

KLIFF: It isn't, actually. One thing you see in most of our peer countries is some use of co-payments. This is especially true in European health care systems, where you do have to pay a small amount. And it's probably smaller than what we're used to here in the States. We're not talking 50 or $100 to go to the doctor. It's more in, like, the five to $20 range. There are small co-payments for prescription drugs, and there are certainly exceptions for low-income citizens in those countries.

The one exception is the Canadian health care system, which I think it's fair to say Senator Sanders has modeled his bill off of. The Canadian system does not have any sort of co-payment, so they're a bit unique in that. They've really influenced health care policy here in the United States, the way Senator Sanders thinks about it. In the Canadian system, everything is financed through tax revenue. There are no co-payments when you go to - I've seen a Canadian hospital's billing office, and it's about two people in a room. There just isn't much money for them to be handling.

DAVIES: So Senator Sanders proposes free medical care for everybody in a government-sponsored plan. And I guess another distinction is whether one would favor the elimination of private insurance carriers. That is Senator Sanders' proposal, right?

KLIFF: Yes, yes. There really is not a role for private insurance in the world that Senator Sanders envisions. One of the things his bill would do would bar private insurance companies from offering the same benefits that the public system offers, and this is how it works in Canada as well. You cannot sell a private insurance plan that covers doctor visits.

Senator Sanders has said there, you know, might be some peripheral - there might be a few small insurance products left, maybe for cosmetic surgery or some things that insurance doesn't cover. But there really isn't a market left in the world that he sees, and that's a very controversial idea. It's one that really tripped up former candidate and Senator Kamala Harris, who seemed to be stuck between, you know, the idea of whether or not to eliminate private insurance because I think there's a lot of frustration with private insurance but also a number of people who've gotten used to the system that we have and are nervous about switching to a plan run by the government.

DAVIES: And Senator Warren's views have evolved a bit - right? - on this. What's her view of the role of private insurance?

KLIFF: Yeah. So she has kind of moved slowly to endorse the idea of eliminating private insurance, but she has not been a backer of that position as long as Senator Sanders. My colleagues and I at The New York Times recently spent a lot of looking into how Senator Warren thinks about private insurance. And we see this slow evolution from the early 2000s, when she was researching bankruptcy at Harvard, finding a lot of people with medical bankruptcy. It was a lot of people who had private insurance and still were bankrupt.

And that really starts a evolution of her policy position from thinking these private insurers might have a role to her position today, which is that we should eliminate the private health insurers. But she has been later to come to that. It's really been in the last year or so that she has quite vocally made it clear, this is how she feels about private insurance, that there should not be a role for it in the American health care system.

DAVIES: Right. But we should also note that she has modified at least the speed at which she would take the country to a Medicare for All plan, right?

KLIFF: Yes. Yeah. So she initially came out with a plan to pay for Medicare for All. This was a big deal for her campaign because she was constantly facing questions in the debate about, how do you pay for it, and where's the money coming from? She put that plan out and then a week later followed it up with another plan that says, actually, I think we should start with a public option; we should start by giving people the option to sign up for a Medicare plan; we - I would do that in the first year of my presidency - and then pushing back the idea of Medicare for All to the third year of her presidency.

So she has been in an interesting place politically, kind of between endorsing Medicare for All, raising her hands at the debate when they ask if you want to eliminate private insurance, but also, she sees a slower transition than Senator Sanders does towards a system that does not have private health insurers.

DAVIES: There have been estimates of the cost of Medicare for All. What's the range?

KLIFF: The range - they're big numbers, and there's a big range. So they are all in the trillions, and we're talking over the course of the decade how much more money the government would need to raise to run a Medicare for All system. And the range is from about 20 trillion to 34 trillion. So again, these are large numbers. We're also talking about the entire American health care system over the course of a decade. And that's a huge range. It's almost - you know, some of the figures on the larger end are nearly double those on the smaller side.

DAVIES: Right. And so these would be the cost to the federal government to do this.

KLIFF: Exactly. So this is how much more money the government would need beyond what it has right now to provide a government-run health care plan to all citizens.

DAVIES: You know, I think the reaction of a lot of people who like the idea of universal health coverage to this huge cost is, well, wait a minute; don't we save a ton of money because we don't have armies of insurance companies, and brokers and administrators arguing over who gets covered for what and generating all this paper?

And we don't have the profit that they earn, right? The government doesn't need to earn a profit, so that's a savings. And then, you know, you give people more regular preventative health care and prevent bigger problems, and there must be savings there. Why does it cost a fortune if it's such a rational way to administer health care?

KLIFF: I think that's a great question. What - and what I often hear from those who support single-payer is that, yes, the government is going to need to raise more revenue. You need more money to provide health insurance to all citizens. But you're also getting rid of all that spending on health insurance premiums. There's so much money that so many households across the United States are paying for premiums. They're paying to get through their deductibles. They're paying copayments when they go to the doctor.

So I think of it less as the government raising a new pot of money but more of a redistribution of who pays. And if you look at these cost analyses, the ones that suggest the government needs to raise trillions more dollars to run a Medicare for All system, they often also find that overall health spending will go down for some of the reasons you mentioned. There'll be fewer administrative costs. There will be less profit margins being picked up at different parts of the health care system. So I think it is possible for two things to be true at the same time - that the government needs to raise a lot of money to run a Medicare for All system, but that overall spending will go down.

But I do think, you know, to speak to one point you raised about the idea - well, everyone's going to get preventive care and that's going to lower health care costs - that might be true in the long term, but there actually - and this is something that came up a lot during the Affordable Care Act debate. There just isn't great evidence that giving people more access to preventative care lowers costs. There's great evidence that it is better for their health to get it, but you have to give a lot of people preventative care. You have to give a lot of flu vaccines to prevent one case of the flu, and you just don't see a lot of evidence in the academic literature finding that this preventative care is a cost saver. In a number of cases, you actually see when more people get health insurance and there's low cost sharing, you don't have pay to go to the doctor, health spending actually goes up. When something becomes free, people use more of it.

So that's one place where it's a little hard to get cost savings, even if you feel like you're doing the right thing by giving people the health care that they need.

DAVIES: Right. And you do have - what? - something like 30 million uninsured people now who would be getting coverage. And that's good, but it's not free.

KLIFF: It is not free. And you have a number of people who have insurance but have really high deductibles or copayments, so they end up putting off treatment. Gallup just put out survey data this week that about a quarter of Americans with serious health conditions report putting off some part of treatment because of the cost. So you think about those folks in a Medicare for All system - they might be using more health care. That's going to drive up some spending even if you have these other mechanisms that are trying to bring down spending.

DAVIES: You know, one of the elements of assessing the cost of doing this is figuring out what doctors and hospitals and other providers would be paid. And I gather Medicare now pays less than private insurers, right?

KLIFF: That's right. And I think that is one of the most, if not the most crucial question in building a Medicare for All plan - is, how much do you pay the hospitals and doctors? Because that's really going to determine how much this thing costs. And legislators and politicians, they're walking this tricky line between wanting to reduce those payments - they are looking at data that shows that Americans' doctors are earning twice what their counterparts earn abroad and thinking, we should be able to see some savings there - but also not wanting to decimate a health care system that has been built around these really robust payments.

So they worry about things like hospitals closing because they're not bringing in enough revenue, or doctors, you know, moving into other professions, or, you know, maybe more plausibly, younger Americans not wanting to go into medicine because they see less of an opportunity to make a good salary. And so this is one of the trickiest questions in building a Medicare for All system, especially in the United States, where we have developed a system that runs on really, really big payments, is - how do you scale back payments? And how much of a scaling back of payments is possible without creating some access issues for the people who are going to use the new health care system?

DAVIES: Sarah Kliff covers health care policy for The New York Times. We will continue our conversation in just a moment. This is FRESH AIR.

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DAVIES: This is FRESH AIR, and we're speaking with Sarah Kliff. She's an investigative reporter. She covers health care policy for The New York Times. We're talking about Medicare for All, its role in the presidential campaign, what it would exactly mean and what it would cost.

I remember a series - I think it was in The New York Times a few years ago - about people going to Europe for medical procedures. And even the cost of travel and staying in nice hotels, they saved thousands and thousands - tens of thousands over what it would cost to get their operations done in the United States. And it made me wonder, well, how do these European countries control those costs? Do they simply regulate what providers are paid directly?

KLIFF: That's exactly - you have stumbled on the exact right answer. They do regulate what providers are paid. So in most European countries and Canada, you have some kind of central planning board that negotiates with the doctors' unions to set payment rates each year. One of the things that's really unique about the United States is that there's huge variation in what doctors get paid for different procedures. You know, I've written a lot about emergency rooms and imaging, and one of the things I see is the prices are all over the map. You know, I've seen MRIs that cost a few hundred dollars. I've seen one MRI that costs $25,000. So it's a huge variation, and it's not really about - how much does the service actually cost? It's more of - how much can a hospital charge? How much market power do they have to charge certain amounts for the services they are providing?

So what would happen in the United States under a Medicare for All system is what happens in other countries. There would be federal regulation of health care prices. And that's actually what happens in Medicare right now. The federal government sets the prices that doctors get paid when they treat Medicare patients. And some version of that would happen for the entire health care system if we had a Medicare for All system.

DAVIES: Right. And so doctors right now accept Medicare patients with the understanding they will make less and they will charge their privately-insured patients more and be happy.

KLIFF: Right. And the question is, like, how much can you - if you're going - could you go to Medicare prices? Could you have everyone come in and pay the prices that Medicare pays? Most politicians at this point don't think so. If you look at the Warren plan, for example, she's looking at having reimbursement rates that are, like, 110, 120% of what Medicare pays - a slight bump from the Medicare rates.

I think one thing that's actually really instructive is if you look at a policy that passed in Washington State. Washington State is currently building the first public option. And initially, they wanted that public option to be cheap, and the way they were going to keep it cheap was by paying lower Medicare reimbursement rates. Through the lobbying and negotiation process, that public plan is going to be paying 187% of what Medicare pays, which is actually pretty similar to what private insurance pays.

And the reason I mentioned that example is I think it's a good - it is an instructive version of what happens when you try and tamp down on health care prices. There's a lot of interests that want to push them up and keep the prices closer to a private health insurance plan.

DAVIES: Right. The lawmakers in the state of Washington were quite committed to making a low-cost, affordable public option. And what happened? Were they convinced that hospitals would close or providers would opt out or - what happened? What was the deciding factor?

KLIFF: It was more about the politics and getting all the members on board - is that they felt like if they wanted to actually pass this public option and not have the hospitals coming after them, have enough, you know - if you think about local legislators, often the largest employer in their district is a hospital. So they're cognizant of the concerns that they have, and I think there are some true concerns about such a quick shock to the health care system. If you were to move reimbursement rates to just Medicare levels, that would be very difficult for hospitals to navigate if you just flipped that switch.

But there's also a lot of politics at play, and so you end up in a situation where there was this ambitious plan to have a government public option that would pay Medicare rates. Instead, we end up with one that's paying nearly twice what Medicare pays. And they estimate premiums for that plan will be about five to 10% percent lower than the premiums for the private plan - so a cost savings, but not the dramatic one that legislators had hoped for.

GROSS: We're listening to the interview FRESH AIR's Dave Davies recorded with Sarah Kliff, an investigative reporter for The New York Times focusing on health care. After a break, she'll talk about how some of the Democratic candidates who favor Medicare for All propose to pay for the plan and about some of the possible consequences of such a dramatic overhaul of the health care system. I'm Terry Gross, and this is FRESH AIR.

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GROSS: This is FRESH AIR. I'm Terry Gross. Let's get back to the interview Dave Davies recorded with Sarah Kliff, an investigative reporter for The New York Times focusing on health care. They're examining proposals by Democrats in the presidential race to create a single-payer, government-run health care system in the country, an idea often referred to as "Medicare for All." When they left off, they were talking about the challenge of controlling costs in American health care.

DAVIES: You know, on the subject of cost, I mean, I'm reminded of a project that you did - maybe it was a couple years ago - where you solicited emergency room bills and accumulated, like, 2,000 of them.

KLIFF: Yes.

DAVIES: And you looked at what people were charged for. What did you find?

KLIFF: I found two main things. One - that the prices were very, very hard to find. You know, the reason I launched that whole project of collecting emergency room bills was that there was no other way to get that information. You can't kind of knock on the hospital's door or call their media relations person and ask, you know, can you send me how much it costs to go to your emergency room? They won't provide you with that information. The only way that I could get it was by having patients send me bills that have that information.

The second thing I learned was just the huge variation in costs for very similar things. A great example of this is pregnancy tests. One of the things I would see is, for women who are of reproductive age, if you go into the emergency room, they will often, as part of procedure, just test you for pregnancy because that might affect your treatment. The price for a pregnancy test in an American emergency room can range from a few dollars to a few hundred dollars. There's one I saw for more than $500 at a Georgia emergency room. And so the variation is so, so, so big, and that is such a unique feature of the American health care system. There is no other developed country where you see something as simple as a pregnancy test having a hundredfold variation depending on which emergency room it's delivered in.

DAVIES: And then there are these facilities charges...

KLIFF: Yeah.

DAVIES: ...That hit you even if you literally get a Band-Aid and an aspirin, right?

KLIFF: Yeah. Yeah. So these are - I think of these as, like, the cover charge for going to the emergency room. This is just the price for walking in the door and seeking a service, even before the various things they'll charge you. You know, I wrote about one father who went into the emergency room because he had cut his daughter's finger while clipping her nails. He got a Band-Aid, and he got a $629 bill for that visit, and $622 of that was the facility fee, the cover charge for just going there; the $7 other dollars was the Band-Aid that they provided.

And again, those charges, they vary so much from one facility to another. They're not kind of posted on the door when you go to the emergency room. The only time you find out your hospital's facility fee is when you get a bill in the mail saying you have to pay that amount.

DAVIES: You know, I think most people in - when they have a medical problem or an injury, are not in any position to ask about or assess prices, and they aren't easy to get anyway. And when you see this kind of variation, I mean, does it suggest that we're - we really need some regulation that people have this wide, wide discretion over what they can charge, can kind of get away with whatever they - whatever number they pick?

KLIFF: So I think if you look across the world at our peer countries, they certainly have decided that you do need this kind of regulation to run a health care system. They think of health care as something akin to a utility, like water or electricity, something we all need to stay alive. And so it's not a normal market. So other countries have decided, OK, because this is such a critical service, we are going to regulate it like a utility, and we are going to decide what prices get paid. And you work this careful balance of paying enough to make sure that those services stay up and running and are high quality, but not letting the prices get so high where you end up with situations in the United States, where, you know, people are scared to go to the emergency room or scared to go to the doctor because they don't know how much it costs, and they know it can be really expensive.

So I think, certainly, the lesson I would take from other countries is that the way to control health care costs and not have this wild variation really seems to run through some kind of government intervention on prices.

DAVIES: If we go to a government-sponsored single-payer health care system, you have all these hospitals that are privately owned, many of them in chains with executives who are well-compensated, does that continue? How does - does that change?

KLIFF: I think it probably has to. I think you're going to see some hospitals who have built an entire business around the way that they are paid now. They build certain wings that they know can bring in the revenue to support them because of how they're reimbursed by private insurance providers. So I think if you go to a system where those hospitals are making less - especially if they're making significantly less, if they're only being reimbursed at Medicare rates - they're going to have to think about how to run a hospital differently. I don't know if it'll be quite as lucrative to be a hospital CEO in a Medicare for All system as it is right now.

So I think it would be a lot of hospitals needing to rethink their business plans. Particularly, I think those that are most vulnerable are those that have a large share of patients who are privately insured. If I think of hospitals that are already mostly treating Medicare and Medicaid patients, they've learned how to get by on lower reimbursement rates. They probably cater to some of those services. But if you are a hospital that's been used to treating a large share of privately insured patients, this will probably a very, very big change for you.

DAVIES: You know, in other industrialized countries that have single-payer systems, are the hospitals private-led institutions, too?

KLIFF: It varies from country to country. If you look at Britain, for example, they've nationalized their health care system. So most of the hospitals there are part of the government; the doctors are government employees. But then if you look in Canada, the vast majority of the health care system is private. The government is contracting with private doctors, private hospitals, just as we do in the United States, except in Canada, they're paying them government-set rates.

You know, in terms of whether they are a for-profit or a nonprofit, that's a little harder to figure out. Right now, most American hospitals are actually nonprofits, even though they're often bringing in large sums of money. So most them do offer - operate as nonprofits. So I'd imagine no one in any of these plans, in the Sanders plan or the Warren plan, is talking about nationalizing our doctors and hospitals, as they do in Britain. All of them seem to envision that, more like Canada, we would continue to have privately employed doctors and hospitals serving patients.

DAVIES: So let's talk about how we pay for Medicare for All or universal coverage, whatever we want to call it. How does Senator Sanders propose to pay for his generous public health care?

KLIFF: Interestingly, Senator Sanders has been the most vocal advocate for single-payer. He hasn't put out a specific plan that says, here's exactly how I would pay for it. Instead, his Senate office has released, a number of times, a set of financing options, the things you could use to pay for Medicare for All. It's often some combination of payroll taxes, employer taxes, sales tax - some kind of different ways to raise money from Americans. I think one of the things they're especially concerned about is doing this in an equitable way, in a way - you know, especially from Senator Sanders' perspective - where the millionaires and billionaires are kicking in more than they are kicking in now. So in the Sanders world, we have a number of options, but no specific list of, OK, this is exactly how I would pay for single-payer.

DAVIES: And Senator Warren?

KLIFF: So Senator Warren has put out probably the most - definitely the most detailed financing plan among the 2020 candidates, where she has a specific combination of payroll taxes, employer taxes, a few other smaller things to raise revenue to get to the $20 trillion that she believes is necessary to pay for a Medicare for All system over the next decade. So really, it takes away those premiums that most Americans are paying; it replaces them with new taxes that are going to raise revenue, send that over to the government to run this new health care system.

DAVIES: You know, when I looked at Senator Warren's plan, and of course, she's known for having detailed plans, I was - it struck me that - I sort of expected most of it to be tax the billionaires; let's make this fair. And that's in there, but it doesn't account for the preponderance of the money. There are a lot of other things, like paying less, like assuming you can really drive down the cost of prescription drugs. There's - it's pretty... complex.

KLIFF: Right.

DAVIES: It's a big challenge, isn't it? Yeah.

KLIFF: There are two levers you can pull, right? One is the overall cost of the health care system - what can we do to get costs down? Because the more you can bring that number down, the less money you need to bring into the government. So you see a number - and so Senator Warren worked with Donald Berwick, who used to run Medicare in the Obama administration, to come up with an estimate of, what do we think is realistic for what we would need to run this health care system? There is a lot of quibbling among academics if the number they came up with is, in fact, realistic. It does rely on some pretty aggressive cuts to prices. Like, we were just talking about, you know, bringing provider payments much closer to what Medicare pays now. So you have this question of, what does it cost? That's the first lever.

The other lever you can pull on is, where does the money come from? Once you come up with how much it costs, you need to fill that hole. And I think there's a number of interesting point - financing choices that Senator Warren makes. One which I find most interesting and surprised a number of economists that I talked to about it was this idea of essentially requiring employers to pay what they've been paying in premiums as taxes to the government. So whatever a big company has been kicking into their workers' health care, they have to keep spending that money; it's just going to go to the government instead of the - instead of going to the private insurers that they're paying now.

And again, like you're saying, you know, that's not necessarily a tax on billionaires. That's premiums that could be going to a lot of middle-class workers right now. So I think it is interesting how she has spread out some of this revenue but is still able to deliver on her promise of not raising taxes on the middle class, which is one of the key things she had said she was going to do with this Medicare for All financing plan.

DAVIES: Sarah Kliff is an investigative reporter covering health policy for The New York Times. We'll talk more after a short break. This is FRESH AIR.

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DAVIES: This is FRESH AIR. And we're speaking with Sarah Kliff. She's an investigative reporter. She covers health policy for The New York Times. We're talking about Medicare for All, single-payer health systems in the context of the forthcoming presidential campaign.

You mentioned that the American Medical Association has typically been against these single-payer systems, right?

KLIFF: Yes.

DAVIES: What about other providers, like nurses? I mean, some - I believe some nurses unions have endorsed Sanders' plan. Are other people in the health care system more welcoming of this concept?

KLIFF: Yeah, I think they are. You know, as you mentioned, the National Nurses United, they're a big, big supporter of single-payer, a big supporter of Bernie Sanders - a key advocacy group. And, you know, when I say the AMA generally has opposed single-payer, I think I often hear from a number of doctors who say, hey, well, the AMA doesn't speak for me; you know, I'm a doctor, and I'd rather practice in a single-payer system. I think you see - especially among primary care doctors, you see stronger support for single-payer than you do among some of the more high-paid specialties, like anesthesiology or orthopedics.

So I think, you know, doctors, they are represented - the AMA is the largest lobby for doctors, but they're not a homogenous group; they are a large group of people with a wide variety of opinions on health care. And you can certainly find a number of doctors, you know, particularly those affiliated with Physicians for a National Health Program - which is a group of doctors who support single-payer - there's a number of them who would prefer to practice in a system like what they have in Canada.

DAVIES: You know, a lot of people are aware that Americans, as a society, spend more of our gross national product - we spend more on health care than other industrialized countries, yet get poorer outcomes. You know, we trail in all kinds of indicia of health. Does that suggest that there's just - there's a lot of savings to be found if we go to universal health care?

KLIFF: I think it does suggest there's significant savings we could get if we were to go to universal health care. I think the question to me is, could we have health care prices in the United States that look like Canada's? I don't know if we can get that low. You know, we have spent decades building a health care system that looks very, very different from our peer countries, and we are starting from a very different place than where they were when they built their universal health care system decades ago.

So I think there is certainly space for health care savings. You know, one of the most obvious to me is the massive amount of administrative costs that we have in the United States that do not exist in other countries. That seems like some pretty low-hanging fruit if we switch to universal coverage. And I think the question is, like, well, how much then can you reduce prices? That's trickier work, and then the trickiest of all is how much can you improve health outcomes in the process? I think one of the things you see in our health care system is there is a decent amount of spending that's just not doing anyone much good, whether it's care that's unneeded or an MRI that's priced at $25,000.

We often spend a lot of money on things that are not getting the value we would want. What you see in other countries is more centralized planning of - what are the things that we want to invest in that we feel like are going to make our population healthier? We don't really think in that kind of centralized, big-picture way in the United States.

DAVIES: You know, if we were to get a single-payer system and administration was centralized in the central government, it stands to reason that a lot of companies would go out of business - I mean, you know, all these brokers, and third-party administrators, and private insurers. And presumably, that would save a lot of money. It might also put a lot of people out of work. Have the analyses of these proposals taken that into account?

KLIFF: I don't think any of the analyses have made estimates of how many people would be put out of work. But I agree with you that's actually something that would need to be thought about - is, what do you do with all these people who work in all these, you know, back offices of health care, the people who code the medical bills and the people who negotiate with health insurers and the representatives for pharmaceutical companies who are going out to doctor offices? There's this whole infrastructure of health care that, you know, other countries did not have to confront when they built their universal systems in the 1940s and '50s. We're starting at a different place. We're starting from a much, much, much more robust health care system that is employing millions of Americans.

So this has been mentioned a little bit here and there in the debates when candidates talk about these issues, but I have not seen a specific retraining program or specific ideas for what industries these people would go in to. And I think it's one of the hard things about health care - is when you look at job growth in the United States, one of the areas that's reliably growing when you see good employment reports is employment in health care. It is such an engine for getting people jobs. So you have this kind of catch-22 of - if you want to reduce health care costs, you're going to need to pay fewer people in that space. But those are - you know, from one person's view, those are administrative costs. From another person's views, that's, you know, a job that's paying them a real salary.

DAVIES: Right, although I guess you'd also have to hire more people to take care of the 30 million uninsured Americans who would be getting better health care.

KLIFF: Yes, yes. So there are opportunities - you know, opportunity that - we have a real need for elder care and home health aides, some industries that currently do not pay very well but, if they were incorporated into a national program, might become a robust area with jobs. So there may be some areas in the new health system that are providing jobs to some of the people who worked in the old health system.

DAVIES: You know, Sarah Kliff, before we let you go, I kind of want to get a big-picture view from you. You know, this debate over expanded health coverage occurs at a particularly contentious moment in American history - I mean, a bitter partisan divide, a president who's under an impeachment inquiry. What do you think the chances are that all of this will result in a significant expansion of health care coverage?

KLIFF: I think the safe bet in Washington and on health care is generally against action. It takes a very, very long time to push through a new government health care program. You know, we had Medicare and Medicaid created in 1965, and then you don't see another major expansion of health care up until 2010, when the Affordable Care Act comes into place. You might also count - in 2003, Medicare did add a drug benefit. But that's essentially three examples of government insurance expansions over the span of decades and decades.

So this work is slow, and it takes time to build the consensus around it. That being said, the one thing that might be a little different right now is how burdened American families feel by health care costs. I spend a lot of my time talking to patients who are struggling with medical bills. And many of these people have health insurance, but they have such a high deductible that they're unable to pay their bills. So I think the fact that you have so many Americans who are not able to pay their bills, who are going into collections, who are getting sued by their hospitals and getting their wages garnished because they have fallen behind on their medical debt - that's a pretty motivating factor for legislators. And it is a - if there is a reason to think Medicare for All might happen in the short-term horizon, I think it's because of how expensive our health care system has gotten and how unaffordable it is for a lot of Americans right now.

DAVIES: Well, Sarah Kliff, thanks so much for speaking with us again.

KLIFF: Yeah. Thank you for having me.

GROSS: Sarah Kliff is an investigative reporter for The New York Times focusing on health care. She spoke with FRESH AIR's Dave Davies. This is FRESH AIR.

(SOUNDBITE OF CHARLES MINGUS' "SELF-PORTRAIT IN THREE COLORS") Transcript provided by NPR, Copyright NPR.