In August, the Yale School of Public Health announced a preprint projecting that a single-payer system could cover every American, avert about 114,000 deaths a year, and cost roughly $1 trillion less than the system it replaces. The release quotes the authors as saying such a system requires “no new discovery, only enactment.”
I have practiced gastroenterology for more than thirty years, twenty in private practice and the rest in the hospital. Physician payment affects me directly, and I say so up front. Coverage decides who can be seen. It does not decide whether someone is there to see them. That second question is the one this study does not ask.
What the model counts
The preprint, which has not been peer-reviewed, is a careful one-year accounting built on 2024 national health spending of about $5.3 trillion. About half of its gross savings come from two lines: a 51 percent cut in drug prices through international reference pricing, and a reduction in fraud extrapolated from Taiwan’s single-payer transition. Paying every hospital and clinician at Medicare rates is the second-largest single line, at about $296 billion.
The 114,000 lives combine two different things. About 62,900 deaths averted come from universal coverage itself. About 51,300 come from reversing coverage rollbacks and other policies enacted since 2025, which could be undone with or without single-payer. That is about 45 percent of the headline.
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To their credit, the authors say what the model leaves out: transition costs, administrative job losses, and how providers would respond to Medicare payment rates. Those are the pieces that decide whether the plan works.
Who delivers the care
The model adds back about $198 billion for care the newly insured and underinsured would use. That is under 4 percent of national spending, which sounds manageable until you ask who provides it.
The Association of American Medical Colleges (AAMC), which advocates for more federally funded residency positions, projects a shortage of up to 86,000 physicians by 2036. The Health Resources and Services Administration (HRSA) projects that physician supply will meet only about 88 percent of demand by 2038. Both projections are made before any coverage expansion. In 2021, about 42 percent of physicians were 55 or older. Medicare-funded residency slots have been capped since 1997, apart from small recent increases, and a new physician takes most of a decade to train. HRSA also projects a shortage of registered nurses that runs through 2037.
The demand would arrive on the day the law takes effect. The supply that has to meet it is already largely set.
The pay cut and the training bill
The cut is larger for some than others. KFF’s review of the literature put commercial physician payment at about 143 percent of Medicare, and hospital payment far higher. Moving everyone to Medicare rates is a real cut for most physicians and a much larger one for hospitals. Medicaid generally pays physicians less than Medicare, so some practices would gain. The net effect depends on each practice’s payer mix, and the model does not estimate how practices or hospitals would respond.
Peer countries do pay physicians less. They also pay for their education. Germany’s public medical schools are essentially tuition-free. England caps tuition and makes repayment income-contingent. In the U.S., the median medical school debt among graduates who borrow was $200,000 for the class of 2024, before premedical borrowing.
Someone pays for a physician’s training: the public up front, or the physician later through pay. A model that cuts the pay but never says who pays up front has not removed the cost, only left it off the page.
What the model leaves open
The model removes cost sharing and adds dental, vision, hearing, and long-term care. It sets no criteria for what a fixed budget will pay for, at what price, or who decides. England answers that question openly through the National Institute for Health and Care Excellence (NICE). In my experience, the U.S. answers it less visibly, through coverage rules, prior authorization, and what patients pay. A universal system would have to answer it too.
The strongest objection
The best reply to all of this is that supply limits are overstated. Researchers affiliated with the advocacy group Physicians for a National Health Program reviewed coverage expansions in the U.S. and ten other countries. They found that use rose far less than most models predicted, with ambulatory visits up about 7 to 10 percent. Proponents also note that Congress could set rates above Medicare.
I take that seriously. But it cuts both ways. If supply limits keep costs down by limiting how much care is delivered, they also limit how many of those 62,900 coverage-driven deaths can be prevented. The estimate assumes that people who gain coverage receive the care. Whether the workforce can deliver it is a separate question, and the model does not answer it.
What I am asking
I am not arguing against universal coverage. Millions of uninsured and underinsured Americans are a real problem, and the authors make a serious case that the country already spends enough.
I am asking that a model this consequential be built around the delivery system, not just the budget. Model what the workforce can actually deliver. Separate the coverage effect from unrelated policy. Say what will fund the residency slots, nursing faculty, and clinical sites that new demand requires. Presented as a headline, the study can be used to justify goals it never tested.
In my judgment, cutting what the system pays while adding demand is likely to worsen the shortage. That is an argument about consequences, not a modeled result, and it is the question the model should have asked.
Brian Hudes is a board-certified gastroenterologist and hepatologist with more than thirty years of clinical experience and a recipient of his specialty board’s thirty-year certification award. He built and ran a private gastroenterology practice for twenty years, then spent more than a decade in hospital-based gastroenterology, most recently as chief of gastroenterology and medical director of GI and endoscopy at a 550-bed Level I trauma center in Pensacola, Florida. He is an assistant professor of medicine at Florida State University College of Medicine.
Those two halves of a career shape the way he writes about medicine and clinical technology. Outpatient practice and hospital-based care fail their clinicians differently, and many systems are designed without a meaningful understanding of both environments.
Dr. Hudes has been building clinical software alongside his medical practice for decades. In 1995, during his gastroenterology fellowship, he co-developed one of the first Windows-based endoscopy reporting systems in the United States. He is now founder and chief executive officer of AiMOS Systems Corporation, where he is developing an AI-native clinical platform for outpatient and hospital-based care. AiMOS has been accepted into NVIDIA’s Inception program.
He writes about the architecture of clinical information, administrative cost growth, physician workforce shortages, board certification policy, and the widening gap between what clinicians need and what the health care technology industry builds. He also publishes The Renaissance Physician, an independent publication examining medicine, technology, physician workforce, and the structure of modern clinical practice.
