The simplest approach: let everyone buy into the same kind of system

Congress could create a nationwide marketplace in which every American could choose among private insurance plans, with the government contributing toward the premium.

Congressional members currently get a federal employer contribution calculated at 72% of the weighted-average premium, up to 75% of the premium of their particular plan. Congress.gov+1

Imagine extending that principle to everyone:

• You choose among competing insurance plans.

• The government pays, say, 70–75% of the premium.

• You pay the rest.

• Lower-income people could receive an even larger subsidy.

• You could keep private insurance rather than having the government take it over.

That would be more like “Congress's insurance arrangement for everybody” than traditional Medicare for All.

A second possibility: a public option

Congress could create a government-run insurance plan alongside private insurance.

You might have:

Private Blue Cross plan | Private Aetna plan | Public Medicare-like plan

You choose.

The Congressional Budget Office has studied this idea. Its cost would depend enormously on how the government set payments to doctors and hospitals and how generous the coverage was. Congressional Budget Office

A third possibility: Medicare for All

This is much more sweeping.

Instead of having employer insurance, ACA insurance, Medicaid and Medicare operating separately, the federal government would essentially become the insurer for everyone.

Advantages:

• Everyone is covered.

• No losing insurance because you lose your job.

• Much less paperwork and fewer insurance companies.

• Potentially greater bargaining power over drug and medical prices.

Disadvantages:

• Government spending would rise enormously, even though individuals would also stop paying many private insurance premiums.

• Taxes would have to increase substantially to replace premiums now paid by employers and individuals.

• There would be a major political fight over what doctors, hospitals and drug companies would be paid.

• The transition from today's system would be complicated.

And this is where the phrase “it would cost trillions” can be misleading. America already spends enormous amounts on health care. CBO currently projects federal health-insurance subsidies alone at $33.6 trillion over 2026–2036. Congressional Budget Office

A universal system would shift a large amount of spending from private premiums and employer payments to government taxes and spending. The relevant question isn't simply “How many trillions would the government spend?” but “What would Americans pay in total—taxes plus premiums plus deductibles and other costs—compared with today?”

Why doesn't Congress simply do this?

This is the political heart of the issue.

The American health-care system has developed around employer insurance, private insurers, Medicare, Medicaid and pharmaceutical companies. Each has enormous economic and political interests.

Also, Americans disagree about the solution:

• Some want Medicare for everyone.

• Some want private insurance with much larger subsidies.

• Some want a public option.

• Some oppose expanding government involvement.

So Congress having a good employer health benefit isn't evidence that universal health insurance is impossible. It demonstrates that the government can provide a substantial employer contribution toward private insurance.

The strongest argument for extending something similar to everyone is essentially:

If a federal employee can have a choice of private insurance plans with the federal government paying most of the premium, why shouldn't an ordinary American have a comparable opportunity?

That's a legitimate policy argument—and it doesn't require eliminating private insurance.

If you want, I can next give you the approximate dollar cost of giving every American the same 72–75% insurance subsidy Congress gets, and who would ultimately pay for it.