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A Watered-Down Medicare for All Won’t Work. Just Ask Ireland.

Democratic candidates are moving away from Bernie Sanders's plan, but moderate health reform would create a crisis of care.

Illustration by Thomas Fuchs

Crowded into the clown car of presidential hopefuls, only Julian Castro, Tulsi Gabbard, Andrew Yang, and the man himself, Bernie Sanders, remain committed to Medicare for All.

In January, Kamala Harris briefly backed the plan, but her initial support resulted in a deafening backlash from billionaires like Michael Bloomberg and Howard Schultz (who told CBS, “That’s not correct. That’s not American.… What industry are we going to abolish next? The coffee industry?”), and her press secretary quickly reassured critics that she would settle for “more moderate” reforms. (She has yet to articulate exactly what that means.) She’s not the only candidate to reverse on Medicare for All, with Cory Booker now endorsing an expansion of Medicare down to age 55 although he, too, had initially supported Bernie Sanders’s bill. Both Kirsten Gillibrand and Elizabeth Warren have endorsed Medicare for All, but are hedging their bets by simultaneously supporting more “moderate,” competing health care legislation in the Senate. Pete Buttigieg and Amy Klobuchar are looking at compromises but have yet to settle on an exact plan; Jay Inslee and John Hickenlooper have gone to the mat for a public option; and former health care financier John Delaney has designed his own Byzantine program from scratch, although he seems to spend the bulk of his time attacking Medicare for All as unrealistic and fiscally irresponsible.

Beto O’Rourke, for his part, has gone from endorsing Medicare for All to endorsing the misleadingly named Medicare for America, a public option policy borne of several years of research from the Center for American Progress. With his support, it has quickly become the most popular moderate plan du jour. It’s even being touted as a “pathway” to Medicare for All, even though it’s really just a fine-tuned, slightly more comprehensive version of what we already have: It would put more Americans on a Medicare program, but the rest would still be required to purchase health insurance, either through their employers or privately. The plan would also introduce more government regulation to health care giants that charge wildly inflated prices for services and medication. This might sound like an improvement, but in fact, a comparable system already exists, in the Republic of Ireland, where it’s created a crisis of care.

The problems are all too recognizable to Americans. Today, the Irish system blends public and private: There’s an (allegedly) expansive public system for the poor, alongside an additional, partially subsidized private system for those who can (allegedly) afford it. To get an Irish Medical Card, which provides coverage under the public system, an elderly person who lives alone has to make less than €500 (about $565) a week. There’s a whole other menu for adults, families, and children, but if you’re single and under 70, you have to make less than €184 a week ($208) to qualify. Hundreds of thousands fall through the cracks in Ireland’s system, too wealthy to get comprehensive benefits from the public system, but too poor to pay for private insurance entirely out of pocket.

Patients aren’t the only people suffering. I visited Ireland in January, where the Irish Nurses and Midwives Organisation—at 40,000 strong, the largest union of nurses and midwives in Ireland—had just started striking and picketing for 24-hour periods (the dispute has yet to be resolved). Their pay is so low that many have had to go to other countries for work, leaving hospitals understaffed, with patient-to-nurse ratios dangerously above recommendations, and waiting times for emergency service rated the worst in all of Europe, far worse than in countries with more comprehensive plans. As one picketing nurse I spoke to outside the Rotunda Hospital in Dublin told me, “You can’t get good care if you don’t invest in nurses’ pay, and you can’t keep Irish nurses in the country if we can’t afford the rent.”

These are not incidental problems, nor are they uniquely Irish. They are the direct result of a health care system that tries to supplement a public service with a private market. If the next Democratic administration attempts the same compromise, rather than plunging headlong into socialized health care, the United States will only suffer from the same disastrous underfunding, wasteful administrative bloat from private insurers, and dangerous conditions for patients and health care providers.

The weaknesses built into the way Ireland provides health care weren’t always so obvious. Beginning in the 1990s, its economy grew rapidly, with foreign investors and tech entrepreneurs flocking to the country in a boom that earned the nation the laughably inapt sobriquet “Celtic Tiger.” More people could afford private health insurance, and the government gradually slimmed coverage down under the premise that Irish patients now had the income to spend on private health care. But when the financial crisis hit, Irish incomes—which had been artificially inflated by a tech bubble and a boom in finance, insurance, and real estate—plummeted, and the number of people enrolled in the public system spiked. (Today, only about 45 percent of Irish people pay for increasingly bare-bones private health insurance, with the rest on the increasingly underfunded public system.)

Even the slightest pressure on the system can create problems. Last May, after decades of dedicated activism, Ireland overturned its abortion ban in a national referendum. But its health system remains woefully underprepared to handle the rush of patients and the intensive nature of the care they will need. After women began calling local general practitioners in January, the government set up a help line, but the physicians were inundated with patients, and many doctors have since removed their names from the list of those who provide services. As one Dublin doctor told The Irish Times, they are simply “not able to cope with demand.”

That realization has left the millions of women who’d fought for their rights facing a stark new reality: As massive as their legal victory was, as much as it reflected a powerful cultural shift among the Irish people, true equality of opportunity and care—and indeed, “choice” itself—can only exist when the system is capable of providing it.

Ireland, for its part, is already recognizing the failures of its system. There have been attempts to institute a socialized health care program there before. As early as the 1940s, a coalition government proposed a free health care program for all mothers and children under the age of 16. But private practices and the Catholic Church, which had a firm grip on the nation’s hospitals, stepped in to crush the plan, claiming that it would put Ireland on a road to socialism, which itself was incompatible with the teachings of the Church. At last, such perceptions seem to be changing. Nine months ago, Ireland’s government laid out a ten-year strategy to create a one-tier, universal system. As expected, the plan has faced attacks from the same enemy of socialized health care that we have here in the United States—the insurance industry. Already, Ireland’s largest health insurer is scaremongering over Sláintecare, with doomsaying over high taxes and the “structural decline” it says would result from reserving public hospitals for public care (never mind the fact that private insurance companies are already outrageously overcharging; it can cost €813 to spend one night sleeping on a gurney in an Irish hospital).

Any politician who backs socialized medical care in the United States is familiar with such pushback. America’s powerful health industry spends more than half a billion dollars annually to build up cozy relationships with lawmakers, whom they can count on to back watered-down bills like Medicare for America. As the fight moves forward, these interests are already attempting to derail the momentum behind socialized medicine, redirecting it toward a system like Ireland’s, which would keep their profit margins intact, while perpetuating the same problems of coverage and care that already exist in our current, broken system.