Healthcare for Everyone

By AFK
First edition, October 26, 2026

The short version

Healthcare can't wait. This plan covers everyone in the country, of every age, in two waves that start as soon as the systems are proven ready. It pays for all medically needed care in full, and it takes private insurers out of deciding what care you get. The basic income builds up over the same years.

• What's covered: everything except truly elective care. That means doctor and hospital visits, prescriptions, mental health, maternity, dental, vision, hearing, rehab, home care and long-term care. Screenings like colonoscopies, prostate exams and children's blood lead tests are covered in full. The only things left out are procedures like a tummy tuck with no medical reason.
• What you pay at the doctor: nothing. No premiums, no deductibles, no copays and no networks. You can go to any doctor or hospital.
• What happens to insurers: they stop selling coverage for anything the public plan covers, and no insurer approves or denies care anymore. Doctors decide, with their patients.
• When: two waves, and each one starts only after it passes readiness tests we publish ahead of time. Wave one is aimed at January 2029 and covers everyone under 27, everyone uninsured, and everyone on Medicaid, CHIP or the ACA marketplace. Wave two is aimed at January 2030 and covers everyone else, including people with coverage through work and people on Medicare.
• What it saves: about $0.62 trillion a year in paperwork, insurer overhead and drug prices, in our middle estimate. Covering everyone in full, including long-term care, costs about $0.82 trillion more. So total health spending in the country goes up about $0.2 trillion, roughly 4%.
• How it's paid for: employers pay 6.5% of payroll in place of premiums. States keep paying their share of Medicaid. Households pay a health contribution of 8% of income up to $125,000 for a single person or $200,000 for a couple, and 16% above that. The first $25,000 per adult is exempt, and each parent's rate is 0.25 points higher for each child. About $110 billion a year from the general budget keeps the middle rate low.
• What it means for families: a family of four making $80,000 pays about $6,700 a year less for healthcare, and their employer stops paying about $20,000 in premiums.

All figures are per year and are our own estimates unless we name a source. They need to be checked by independent actuaries before this goes anywhere.

How it connects. This is the full plan behind commitment 4 of A Way Forward, Together, which is laid out in more depth in the commitments in full. Healthcare has its own trust fund, kept separate from the money for the basic income. Paying for it shows both side by side with every other commitment.

What we pay now, and what it buys

These are 2024 figures (CMS, National Health Expenditure Accounts).

• Total health spending in the country: about $5.3 trillion, roughly 18% of the economy. Other wealthy countries spend 8% to 12% (Commonwealth Fund, 2024).
• Hospitals: about $1.6 trillion. Doctors and clinics: about $1.1 trillion. Prescription drugs from pharmacies: about $467 billion.
• Private insurance premiums: about $1.6 trillion. Businesses pay about $753 billion. The rest comes out of workers' paychecks, from people who buy their own plans and from public employers.
• Out-of-pocket costs: about $557 billion in deductibles, copays and care that isn't covered.
• What it buys us: the U.S. ranks last of ten wealthy countries overall, last on fairness and last on four of five measures of health outcomes. Our life expectancy is more than four years below the average of the other nine. About 26 million people have no insurance, and nearly a quarter of adults who do have insurance don't have enough (Commonwealth Fund, Mirror, Mirror 2024).

Why we pay more than the care actually costs

The bill is a lot bigger than the care. The extra comes from three places.

• Paperwork. In the spending researchers were able to measure, administration takes about 34% in the U.S. and about 17% in Canada. That's about $2,500 per person a year here and about $550 there (Himmelstein and others, Annals of Internal Medicine, 2020, using 2017 data). Hundreds of insurers each have their own rules, forms, networks and approval steps, and every hospital and clinic has to hire billing staff to keep up with them. Insurer overhead alone is about 7.9% of all spending here and 2.8% in Canada. Traditional Medicare spends under 2% on administration (KFF).
• Prices. Private plans pay hospitals about 254% of what Medicare pays for the same care (RAND, 2024). Americans pay about 2.8 times what other wealthy countries pay for prescription drugs overall, and more for brand-name drugs (RAND, 2024). Medicare's first negotiated drug prices cut costs 22% in 2026, and the next round cuts them 44% in 2027 (CMS, via American Action Forum).
• Waste. One estimate puts total waste at $760 to $935 billion a year. That includes about $266 billion from how complicated the paperwork is and about $231 to $241 billion in prices higher than the care should cost (Shrank and others, JAMA, 2019).

What removing insurers saves

These are the savings from having one public plan, one set of rules and one set of prices. This is our middle estimate. The cautious and optimistic versions come after.

• Paperwork and insurer overhead: about $0.50 trillion. If our administrative costs fell all the way to Canada's level, we'd save about $0.66 trillion. We assume we only get three-quarters of the way there, since some American complexity will stick around.
• Drug prices: about $0.12 trillion. One public buyer negotiates every drug, at roughly 30% below today's brand-name prices. About 15% of those savings is set aside as a reward for drugs that are real breakthroughs, so new medicine still pays.
• Fraud and improper payments: not counted. Medicare's improper payment rate runs about 7% to 8% a year (CMS), and on a plan this size, every point is about $25 billion. One claims system watching the whole country should do better than what we have now, but we won't count those savings until audits show them.
• Total savings: about $0.62 trillion a year.

And these are the added costs of covering everyone in full:

• Covering the 26 million people who are uninsured: about $0.08 trillion.
• More care when cost isn't in the way: about $0.30 trillion. People who skip care today because of their deductible will start getting it. That's the point, and it's a real cost.
• Full dental, vision and hearing: about $0.05 trillion more than today.
• Long-term care and home care: about $0.35 trillion.
• More doctors, nurses and rural hospitals: about $0.04 trillion.
• Total added: about $0.82 trillion.

What it adds up to: generous coverage for everyone, for about 4% more than the country spends on health today. The savings don't disappear. They pay for most of the cost of ending deductibles, covering the uninsured and adding long-term care. Long-term care is the piece most likely to run over. Paid long-term care already costs about $500 billion a year, and most care is still given for free by family members, some of whom will turn to paid help once it's covered. That's why it's the biggest added cost and the first thing the actuaries check every year.

• Cautious case: savings of about $0.41 trillion and added costs of about $1.10 trillion, so national spending goes up about $0.69 trillion.
• Optimistic case: savings of about $0.87 trillion and added costs of about $0.65 trillion, so national spending goes down about $0.22 trillion.

Our middle estimate sits near the high end of what the Congressional Budget Office found, because our plan covers more than the designs CBO looked at. CBO found total health spending could change anywhere from $0.7 trillion less to $0.3 trillion more, depending on the design (CBO, 2020).

What other countries teach us

Every wealthy country covers everyone. They do it in different ways, and each one has something worth copying and something to avoid.

Taiwan: one public plan, built fast

• How it works: one national insurer, started in 1995, covers everyone. Everyone carries a smart card with their history and medicines on it, and bills go straight to the national insurer and get paid automatically.
• What works: administrative costs under 2%, health spending around 6% of the economy, and a national plan launched in about a year. Taiwan did have a head start. It merged 13 insurance programs that already covered more than half of its 21 million people (NPR, 2008).
• What doesn't: politicians kept premiums too low, so the fund ran short and doctors got squeezed into very short visits.
• What we take from it: copy the smart card and automatic payment. Avoid the underfunding by having actuaries set the contribution rates, not politicians.

Canada: single payer, but too narrow and too tight

• How it works: each province runs one public plan for doctors and hospitals. Doctors are private and patients choose freely.
• What works: no bills for doctor and hospital care, and low administrative costs.
• What doesn't: the typical wait from a family doctor's referral to treatment was 30 weeks in 2024, the longest on record (Fraser Institute). Hospitals live on fixed yearly budgets, so doing more surgeries doesn't bring in more money. Prescription drugs, dental and vision mostly aren't covered.
• What we take from it: pay hospitals for the care they actually deliver, not a fixed budget. Build enough capacity before launch. Cover drugs, dental and vision from day one.

United Kingdom: free care, stretched thin

• How it works: the government runs most hospitals, and care is free when you get it.
• What works: among the best in the world on affordability and on keeping administration lean (Commonwealth Fund, 2024).
• What doesn't: about 7.4 million cases were waiting for hospital treatment in August 2026, and only about 65% had waited less than 18 weeks, against a standard of 92%. Beds have been more than 90% full since 2021, partly because patients who are ready to leave can't get the care they need at home or in a facility (British Medical Association, 2026).
• What we take from it: keep spare room, with hospitals no more than 85% full. Put long-term and home care inside the system so hospital beds don't fill up with people waiting to go somewhere else.

Germany and Japan: one price list for everyone

• How it works: in Germany, nonprofit sickness funds all pay the same negotiated prices, and copays are capped at 2% of income (1% for chronic illness). In Japan, the government sets a national price for every service and drug and revises it every two years through a council of payers, providers and the public (Japan Health Policy NOW).
• What works: plenty of capacity and short waits. Japan keeps costs down while caring for the oldest population in the world.
• What doesn't: Japan's system rewards volume, with very frequent visits and long hospital stays.
• What we take from it: one national price list, revised every two years by an independent council, with prices that reward good results and not just more visits.

The Netherlands and Switzerland: private insurers under strict rules

• How it works: everyone has to buy a basic plan from a private insurer, with strict rules and subsidies.
• What works: good access and strong results. The Netherlands ranks near the top overall (Commonwealth Fund, 2024).
• What doesn't: Switzerland ranks near the bottom with the U.S. on administrative waste, and both countries keep deductibles that discourage people from getting care.
• What we take from it: competing insurers add paperwork without lowering prices. That's a point in favor of one public plan.

Australia: a public plan plus a private tier

• How it works: public Medicare for everyone, with optional private insurance for faster elective surgery.
• What works: it ranked first overall in 2024, with strong results and little waste (Commonwealth Fund).
• What doesn't: people without private insurance wait longer for planned surgery, and the private tier pulls doctors away from public hospitals.
• What we take from it: no second layer of private coverage for care the plan already covers, so everyone uses the same system and the same waiting list.

The Nordic countries: a legal right to timely care

• How it works: regional public systems paid for with taxes. Sweden guarantees maximum waits for each step of care, and in Denmark, if your wait runs too long, you can go to another hospital and the public system pays.
• What we take from it: write wait-time guarantees into law, and give people the right to get care somewhere else at the plan's expense when a guarantee is missed.

At home: Medicare and the VA

• Medicare already pays for care for about 68 million people, with administrative costs under 2% and a claims system that handles more than a billion claims a year. It's what we build on.
• Medicare has its own weak spot, though. It loses billions to improper payments every year, so fraud checks have to be built in from the start.

How we'll run it

This is how we'd put those lessons into practice.

• One national price list. Every provider gets paid the same rate for the same service. An independent council of doctors, hospitals, patients and economists sets the rates and revises them every two years. Rates start at about what providers are paid on average today, minus the billing costs they won't have anymore, so hospitals don't lose money in the switch. Rural hospitals and children's hospitals get extra.
• Pay for care delivered, not fixed budgets. Hospitals get paid per patient and per procedure, with bonuses for good results and penalties for readmissions that could have been avoided. More care means more money, so nobody has a reason to make people wait.
• Paid in 14 days, electronically. One claim form, one portal and one national digital health card. Everyone is automatically covered, so nothing needs checking before treatment. Clean claims get paid within 14 days, or the plan pays interest.
• No prior authorization. Doctors order care. An independent body publishes clinical guidelines based on evidence, and the plan looks at billing patterns after payment to catch fraud and overuse, without standing between a patient and treatment.
• Fraud checks built in. Every claim runs through the same system, so strange billing patterns show up across the whole country. Providers caught cheating the plan lose the right to bill it.
• Wait-time guarantees. Maximum waits for primary care, specialists, surgery and mental health care are written into law, and waits are published by region every month. If the plan misses one, you can go somewhere else, even out of state, and the plan pays.
• Capacity before launch. Starting in 2027, fund thousands more residency slots for new doctors, more nursing school seats and more community health centers. Hospitals stay no more than 85% full, and money for new beds and equipment comes from a separate budget so everyday costs don't crowd it out.
• Long-term care inside the system. Home care and nursing care are covered along with everything else, so hospitals don't fill up with people waiting for somewhere else to go.
• Drugs priced by what they're worth. The plan negotiates every drug. New drugs that are real improvements get higher prices, as in Germany. Drugs that add nothing new get paid like the drugs they copy. Prizes reward the biggest breakthroughs.
• A trust fund that can't be starved. All health money goes into one trust fund that can only pay for care. Independent actuaries set the household rate every year so the fund balances with three months in reserve. That's the fix for what went wrong in Taiwan.
• Accountability. A national health ombudsman takes complaints. Every region's waits, results and spending are published, and Congress gets an independent audit every year.

When it happens

• 2027: pass the law and start building capacity. Set benefits, rates and how it's paid for. Fund training slots and clinics right away.
• 2028: build the systems. Expand Medicare's claims system, issue the health card, set the first national price list and enroll everyone automatically using tax, Social Security and Medicaid records.
• Wave one, aimed at January 2029: everyone under 27, everyone uninsured, and everyone on Medicaid, CHIP or the ACA marketplace, roughly 160 million people. The people the private market serves worst come first.
• Wave two, aimed at January 2030: everyone else, including people with coverage through work and people on Medicare. Employer premiums end the same day the employer contribution starts, so no business pays both.
• Why two waves: the claims system and price list prove themselves on half the country first. The closest examples are sobering. Medicare signed up 19 million people in 11 months in 1966, with far less coverage, and HealthCare.gov crashed on its first day in 2013. So the dates are targets, and the readiness tests decide.
• Readiness tests, published ahead of time: a wave starts only when the claims system has handled the wave's full volume alongside today's payers for six months and pays 95% of clean claims within 14 days, the national price list has been public for a year, everyone in the wave is enrolled and has a card, enough doctors and hospitals have signed on in every region to meet the wait-time guarantees, and the trust fund has its three months in reserve. An independent board signs off on each test in public. If a test isn't met, the wave moves back six months at a time, and nobody loses the coverage they have in the meantime.
• What to expect: honestly, one or both waves could slip by about a year, to 2030 and 2031. Wave two never starts until wave one has run cleanly for a full year.

How it's paid for

The money families and employers pay insurers today goes to the public plan instead, and it's split more fairly. None of it comes out of the money for the basic income.

• New federal spending: about $2.5 trillion a year in our middle estimate. It replaces about $1.6 trillion in premiums, $557 billion in out-of-pocket costs, the medical part of workers' comp and seniors' Medicare premiums, plus about $0.2 trillion more for covering everyone in full, since the added costs run a little ahead of the savings.
• Employers: a 6.5% payroll contribution, about $0.78 trillion. That's about what employers pay today in premiums and workers' comp medical costs, so business as a whole comes out about even. Employers that offer good coverage now will pay less, and those that offer none will pay more. Employers get a tax credit for passing their savings on as higher wages.
• States: keep paying their share of Medicaid, about $0.3 trillion. States stop running Medicaid but keep putting in what they spend now, growing with the economy.
• Households: a health contribution of 8% of income up to $125,000 for a single person or $200,000 for a couple, and 16% above that, about $1.29 trillion. The first $25,000 of income for each adult is exempt. Each parent's rate is 0.25 points higher for each child, with no cap, so a couple with two kids pays 9% and 17%. Every child's own care is covered in full. The add-on just asks parents of bigger families to carry a little more of what their kids' care costs. It raises about $20 billion a year. That money, plus about $2 billion saved by halving the basic income from a family's fifth child on, is what moves the single line up from $100,000 to $125,000. The contribution replaces workers' premiums, deductibles and copays, and the basic income doesn't count as income for it. Keeping the middle rate low means single workers and middle-income couples don't pay more than they do now, and about $110 billion a year from the general budget makes up the difference. In the cautious case the two rates would be about 10% and 21%, and in the optimistic case about 6% and 12%. Once every tax is stacked up, high earners will report less income, which could add about half a point to the upper rate. The actuaries' yearly reset catches that.
• The trust fund rule: all of it goes into the health trust fund, and actuaries reset the household rate every year.
• One-time start-up costs: about $85 to $155 billion between 2027 and 2032. That covers the claims system and health card, help for people who work in insurance and billing, keeping the private market steady between the two waves, and training and clinics that start before the trust fund collects anything. Paying for it counts these in the general budget, so they don't raise the household rate.

What it means for families

These compare the health contribution with what a typical family pays now in premiums and out-of-pocket costs, using our middle estimate. They leave out the basic income, which is counted separately.

• A family of four making $80,000, with coverage through work: pays about $9,350 a year today and about $2,700 under the plan, so they're about $6,650 better off. Their employer stops paying about $20,000 in premiums and pays about $5,200 instead, which frees up nearly $15,000 that can go to wages.
• A single worker making $60,000: pays about $2,450 today and about $2,800 under the plan, about $350 more. They come out ahead once their employer passes on its savings of about $3,100.
• A couple making $150,000 with no kids: pays about $8,850 today and about $8,000 under the plan, about $850 less, and more once their employers pass on the roughly $4,250 they save.
• A couple making $400,000: about $34,100 more a year. This is the biggest thing the plan asks of anyone.
• Anyone with a serious illness, anyone uninsured and anyone on Medicaid: far better off. No bills, no networks and no medical debt.
• Seniors: no more Medicare premiums, drug plan premiums or Medigap, which is worth about $3,000 to $5,000 a year for a lot of people.

Add in the basic income at launch, and the $80,000 family comes out about $18,000 a year ahead before any raise. A single worker making $60,000 comes out about $1,200 ahead. Paying for it adds up every piece, including the carbon fee and the leave premium, for all four households.

How it fits with the rest of the plan

• The basic income keeps its own money. Health has its own trust fund and its own contributions, so it doesn't take dollars from the basic income, the services or the debt limit.
• The real limit is how much a household can carry at once. The VAT, the smaller standard deduction, the health contribution and the Social Security change all land on the same paychecks. Added up, a $60,000 worker in a state with no income tax keeps about 59 cents of an extra dollar, compared with about 75 cents today, though today's number leaves out the premiums that already hold every paycheck down. A top earner keeps about 25 cents, close to the point where higher rates stop bringing in more money. For most working families, the basic income and the end of premiums more than make up for it. The full picture is in Paying for it, under "All the taxes, added up."
• The basic income still starts in 2029, at $500 per adult and 250perchild(125 from a family's fifth child on), and grows toward full size as automation pays in. If AI's gains come slowly, adults may stay at $500 through most of the 2030s.
• Every piece gets tested. How patients, doctors, hospitals and employers are likely to react to each part of this plan, and what we'd watch for, is in Following the chain, section 4.

Still open

• Where the upper rate starts: the single line is now $125,000, but the couple line stayed at $200,000. So two people making $125,000 each who get married pay 16% on their top $50,000. Fixing that marriage penalty would cost about $50 billion a year. We also haven't decided whether to phase the upper rate in over a range so there's no sudden jump for people just above the line.
• Pace: the readiness tests set it. What's still open is whether a state whose systems pass early can bring all its residents in before wave two.
• Wait-time guarantees: the exact maximum waits for each kind of care.
• What counts as truly elective: a short list, written by the clinical council, of procedures with no medical purpose.
• Who "everyone" includes: the basic income goes to citizens, green card holders and other legal residents after five years. Healthcare has to answer the same question for the roughly 11 to 14 million people here without legal status. Emergency care is covered for everyone either way. The open question is primary and preventive care, which is cheaper than emergency care and protects everyone's health.
• What income the household contribution counts: our estimate uses the income on a tax return (wages, business income, investments and pensions), not counting the basic income. Whether Social Security benefits count is still open.
• Doctors who don't sign on: rates start near today's average. That's a raise for practices that mostly see Medicaid patients and a cut for some that mostly see privately insured patients. The readiness tests require enough providers in every region before a wave starts, and the price council has to watch for specialties where sign-up lags.
• The plans that cover people now: the law has to settle how self-insured employer plans (governed by the federal ERISA law), union-negotiated plans, federal employees' coverage, military TRICARE and Medicare Advantage end or fold in, and how union members who gave up wages for their coverage get that value back.

Sources

• CMS, National Health Expenditure Accounts, 2024 highlights.
• Commonwealth Fund, Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System (September 2024).
• Himmelstein, Campbell and Woolhandler, "Health Care Administrative Costs in the United States and Canada, 2017," Annals of Internal Medicine (2020), via TCTMD.
• Jiwani and others, billing and insurance-related costs, BMC Health Services Research (2014), via AJMC.
• Shrank, Rogstad and Parekh, "Waste in the US Health Care System," JAMA (2019), via The Fiscal Times.
• RAND, Prices Paid to Hospitals by Private Health Plans (2024); RAND, international prescription drug price comparisons (2024).
• KFF, insurer overhead and Medicare administrative costs; KFF 2025 Employer Health Benefits Survey.
• American Action Forum, Medicare negotiated drug prices for 2027.
• Fraser Institute, Waiting Your Turn: Wait Times for Health Care in Canada, 2024.
• British Medical Association, NHS backlog data analysis (2026).
• NPR, "Taiwan Takes Fast Track to Universal Health Care" (2008).
• Japan Health Policy NOW, cost control through the national fee schedule.
• Congressional Budget Office, How CBO Analyzes the Costs of Proposals for Single-Payer Health Care Systems (December 2020).