America already pays for a universal health system. It just doesn’t get one.

America does not have a health insurance problem. It has a health care shortage sold at monopoly prices. Every plan of the last thirty years — Clinton’s, the Affordable Care Act, Medicare for All — is a plan about who writes the check. None of them builds a single hospital, trains a single doctor, or opens a single clinic. That is why the ACA insured twenty million people and rural hospitals kept closing anyway. A card is not care.

The Overview The Plan The Story

Read the plan

The OverviewEvery part of the plan, in about twenty minutes. Nothing left out.The American government already spends $2.56 trillion a year on health care, more than the entire health system of 27 of the 37 advanced nations. The diagnosis, the four things this plan does, what changes in the first year, and what it costs.

Read the overview18 min read

The PlanThe complete proposal, written to be read in one sitting.Build the capacity. Open the professions. One payer, one price. Ban the dividend rather than the owner. The ten-year transition, the technology that ends the paperwork, and what it costs, with the background moved into the appendices below.

Read the plan58 min read

The Implementation AppendicesThe history, the law, the mechanisms and the numbers behind the plan, one topic per appendix.Thirteen standalone explainers: how Hill-Burton built the country's hospitals, how Medicare sets prices, the government's power over drug patents, what the insurance industry has become, the full cost table, why transitions fail, and why the filibuster has to go.

Browse the appendices13 appendices, 2 hr read

Harry and Louise, Thirty-Five Years OnWhat the next ten years look like for one household in Wisconsin.In 1994, two actors at a kitchen table killed a health care bill by finding a true fear and standing on it. This is the same couple, thirty-five years later, followed all the way through, including the night it gets tested.

Read the story12 min read

Ownership: Ban the Dividend, Not the OwnerWhy private ownership is not what America gets wrong, and the legal instruments behind the rules that make it safe.The OECD data does not say what everyone assumes. Korea and Japan run two of the best systems on earth with private hospitals, under conditions America has never imposed. The case for conditions rather than conversion, and the legal ladder that defends it.

Read the argument20 min read

What Else to BorrowEight things the successful systems do that this plan should take.Setting a hard national budget, three drug mechanisms better than pure negotiation, primary care built as infrastructure rather than left to the market, and a quality apparatus that costs almost nothing. And the five worth taking first.

Read the lessons9 min read

What Every Plan Leaves OutLong-term care, mental health, dental, vision, hearing and public health.The largest mental health facilities in America are county jails. Long-term care is the biggest gap in American life and almost no plan addresses it. Nine things that fall outside the coverage debate and that a plan has to answer anyway.

Read the gaps12 min read

How This Compares to Medicare for AllWhat we keep, what we change, and where their approach is arguably better.Medicare for All was never wrong. It is half a plan, a well-drafted bill about who pays, containing almost nothing about whether the care exists to be paid for. We keep most of it and add the missing half.

Read the comparison4 min read

Six Trillion Dollars a YearWhere the money goes, and what the country gets for it.America will spend about $6.0 trillion on health care in 2026, 19% of everything the country produces. The government already pays more than half of it. This is what that buys, and what it does not.

Follow the money16 min read

What the System Does to PeopleWhat is actually wrong with American health care, for the people it treats and the people who work in it.Keith Swihart lost his sight and his toes while insured and employed. Ray Brovont was fired for saying one doctor cannot be in three places at once. Nine problems, and they compound.

Read the problem20 min read

Where the U.S. Ranks in HealthFour rankings from live World Bank, WHO and OECD data, and where America lands on each.The healthiest countries, the most efficient systems, who owns the hospitals and who pays, across 160 countries. The United States is 43rd on health, last of 35 advanced nations on cost, and not in the top ten of anything. Interactive charts, every figure sourced.

Explore the rankings6 pages of charts, 10 min read

About This Plan

The American government already spends $2.56 trillion a year on health care — $7,269 per person, and more than the entire health system, public and private combined, of 27 of the 37 advanced nations. Americans then pay for it a second time in premiums, deductibles and cash, and get the worst outcomes in the rich world.

This plan does four things, in this order. Build the capacity: a ten-year federal program for hospitals, clinics, maternity units and long-term care, placed where people actually live. Open the professions, because the doctor shortage was manufactured and we know exactly when. One payer and one price, negotiated in the open. And ban the dividend rather than the owner — providers may stay private, as they are in Japan and South Korea, but not extract from a public system.

The money arrives first and the care arrives second, and that is a design decision rather than an apology. Building hospitals takes years; almost everything that makes an insured middle-class American hate this system needs nothing built. The governing rule of the whole transition is that nobody loses anything before they gain something.

This is a beta. We are publishing it early, unfinished, and open to being wrong, because we would rather be corrected now than after it is printed. If you think a number here is wrong, or a piece of the design would fail in practice, tell us.

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