Bri Moss was buying cat food at Hy-Vee when she answered her phone for an interview with The Daily Iowan. A part-time waitress and secretary, she runs an advocacy campaign in support of Medicare for All out of Dubuque. She partners with National Nurses United, a 150,000-member organization that has endorsed two bills in Congress that would replace private insurance with a single-payer health-insurance plan.

When knocking on doors and speaking with Democrats in the Dubuque area, she frequently answers logistical questions from those skeptical of the cost of Medicare for All. She references some talking points prepared by the nurses’ union to anticipate what kind of questions people may pose.

One question those she talks with sometimes ask is what would happen to a friend or family member employed by the insurance industry or health-care administration if private insurance no longer existed.

“A lot of people that will lose their jobs will have the opportunity for a reassignment within the field,” she says, because some services such as providing health care, billing, data-tracking, and management still need to happen under an expanded Medicare system. Medicare is a government-run insurance coverage for Americans over the age of 65.

She then directs them to a section included in the House and Senate versions of the Medicare for All bill, which dedicates funds to retraining employees whose jobs would be affected by condensing private insurance into one government-run program.

Depending on which congressional chamber’s bill you look at, retraining employees, replacing wages, and subsidizing education for workers affected by Medicare for All would either make up at least 1 percent of the federal Medicare for All budget (House version) or up to 1 percent (Senate version).

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While not frequently discussed in the three Democratic debates (where health-insurance coverage took up more than an hour of national television time), some research organizations have written that a critical challenge to implementing a Medicare for All plan will be the economic transition for those employed by the private health-care and insurance industry.

Health-based companies comprise 16 out of 225 insurers in Iowa — small potatoes compared with Iowa’s looming life- and property-insurance businesses. Private health- and medical-insurance carriers employ 2,607 people in the state, according to data from the Bureau of Labor Statistics’ Quarterly Census of Employment and Wages database. The largest health insurer in Iowa is Wellmark Blue Cross Blue Shield.

“Remember, we’re not talking about your insurance agent downtown,” Iowa State University economics Associate Scientist Dave Swenson said of the jobs data. “We’re talking about insurance carriers, big companies that offer insurance plans.”

Without a detailed transition plan in place, it’s impossible to be completely certain what would happen to those jobs. For advocates of a single-payer, streamlined insurance system, reducing administrative bureaucracy in the insurance industry and health-care administration is core to their message of lowering overall costs for patients.

In other words, supporters of Medicare for All say that fewer employees doing administrative work means fewer costs for people seeking medical care, Swenson said.

“We’re eliminating jobs that don’t have anything to do with direct health-care provision,” Swenson said.

According to an analysis done on the 2017 Medicare for All Act by Political Economy Research Institute at the University of Massachusetts — Amherst, up to 65 percent of jobs in health-insurance administration nationwide would be eliminated, meaning the jobs wouldn’t exist in either the public or private sector.

While the census doesn’t put out numbers of all administrative employees in the private-insurance industry, the institute used data from the 2017 U.S. Quarterly Census of Employment and Wages to estimate that the private health-insurance industry employs around 800,000 people nationwide. The nurses union Moss works with funded the study.

Some researchers have predicted a Medicare for All system would cause job losses in hospitals as well. A Navigant study that was funded by an anti-public-option group found that if 85 percent of Iowa’s health-insurance market moved from commercial, employer-based options to the public option, then 52 rural hospitals in Iowa would be at risk of closing.

During the Sept. 12 Democratic presidential-nomination debates, Sen. Elizabeth Warren, D-Mass., responded to a critique from Sen. Amy Klobuchar, D-Minn., to defend the cost-savings claim of independent Vermont Sen. Bernie Sanders’ Medicare for All plan.

“Doctors won’t have to hire people to fill out crazy forms,” Warren said. “They won’t have to spend time on the phone arguing with insurance companies. People who have sick family members won’t have to get into these battles.”

Warren is one of the cosponsors on the Medicare for All Act that Sanders, her Senate colleague, introduced in 2017. Other Democratic presidential hopefuls currently serving in the Senate who have cosponsored the bill each session include New Jersey Sen. Cory Booker, and California Sen. Kamala Harris. In the House, Rep. Tulsi Gabbard, D-Hawaii, cosponsors a similar Medicare for All proposal. While all support a single-payer plan, each except Warren and Sanders have said they’d be open to a role for private insurers.

One key question when considering Medicare for All is whether reducing administration would indeed lower costs for health-care consumers.

Sanders claims that the administrative costs for Medicare — a program which he hopes to expand to cover everyone — are much below that of the private health-care industry. Total expenditures in calendar year 2018 for Medicare were $741 billion. Of that, $9.9 billion was considered “administrative expenses,” or around 1.3 percent of total expenditures. Various research findings estimate administrative costs comprise between 12.3 percent and 17 percent of private-insurance spending, according to a 2017 Politifact analysis.

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While the private sector’s share of administrative costs looks significantly higher than those of Medicare, critics have argued that Medicare’s spending look artificially low because Medicare uses the Social Security administration to track payments and patients.

Ahead of the Iowa caucuses, health care is the No. 1 issue on likely Iowa Democratic caucusgoers’ minds, according to an August Monmouth University poll, But, according to that same poll (which receives an A+ rating from FiveThirtyEight), likely caucusgoers offer lukewarm support for a Medicare for All system with no private insurance — 21 percent are in favor of eliminating private insurance for a single-payer plan and 56 percent support allowing people to opt-in to Medicare.

At a Sept. 12 watch party hosted by former Vice President Joe Biden’s Iowa campaign, attendee Marjorie Tully said although affordability was her top concern with health care, she was skeptical that the jump from the current insurance system to Medicare for All would fix problems of affordability and access to care. Tully is a medical coder for the University of Iowa Hospitals and Clinics, and managed a physician’s office for about 20 years.

Iowa Insurance Commissioner Doug Ommen, whom Gov. Terry Branstad appointed in 2017, frequently talks about what he perceives as “structural flaws” with the country’s last major health-care reform, the Affordable Care Act, in its individual health-insurance market. He said he’s wary of a health-insurance overhaul as an insurance regulator, because he said he believes fixes to the ACA can bring down costs of premiums to keep healthy young people, small-business owners and farmers in the individual market.

For Iowans in general, he said, job loss from health-insurance companies is a smaller problem than access to affordable care. But, he said, that job loss was still a separate issue to consider.

“Those services are being administered here by Iowa employers like Wellmark,” Ommen said. “And that is important to our state, that those jobs stay here.”