Appendix J: The full cost table, its assumptions, the one-off costs, and the unpriced liability

This appendix supports the sections "What it costs and who pays" and "Cancel medical debt" in the plan. The figures are annual at maturity, around year 10, in today's dollars.

How the numbers are built

The comparative international figures used throughout the plan are computed from World Bank, WHO, and OECD data and are reproducible. Cost figures described as estimates or given as ranges are built from public data, not from a scorer's model, and where the answer is a range, the text gives a range. Household dollar figures are illustrative until the household calculator is live. Where a claim rests on a single source or on secondary literature, the text says so.

International comparisons are made in purchasing-power terms, which adjusts for what a dollar actually buys in each country. That adjustment raises the other countries' figures, so it makes the American gap look smaller than a straight currency conversion would. Every comparison in the plan is therefore conservative in America's favor.

The table

	Annual at maturity
What the plan saves
Administrative and billing eliminated	$250–400B
Hospital and physician prices moved to a unified schedule	$250–400B
Drugs, through public pricing, the prize fund, and generics	$150–250B
Medicare Advantage overpayment ended	$40–60B
Avoidable acute care reduced	$50–100B
Gross savings	$740B–1.21T
What the plan spends
Operating the new capacity	$150–300B
Long-term care benefit	$200–300B
Induced use once cost-sharing goes to zero	$100–200B
Covering the uninsured and underinsured	$100–150B
Dental, vision, and hearing	$75–100B
Capacity build-out, 10 years	$75–100B
Mental health and addiction build-out	$50–75B
Health Workers Transition Guarantee, front-loaded	$40–60B
Physician pipeline: residencies, tuition, new schools	$30–40B
Public health rebuild	$20–40B
Nursing and allied pipeline	$15–25B
No-fault injury compensation, national health record	$15–30B
New spending	$870B–1.42T
Net	$680B worse to $340B better, centered near spending-neutral

The base against which all of this is measured is roughly $6.0 trillion of national health spending in 2026, about 19 percent of GDP, of which $2.56 trillion is already public money.

What the savings lines assume

Administrative and billing, $250–400B. Estimates of total administrative cost in American health care run from 15 to 30 percent of spending, and billing-and-insurance-related costs alone are put at around $500 billion a year across payers and providers. The plan does not claim all of it. Billing does not vanish on the provider side, because hospital budgets adjusted for case mix still require coding every discharge, and physicians remain on a fee schedule, so claims work shrinks rather than disappears. The range assumes that the payer-side administration of private insurance, the PBMs, and most of the adjudication industry go away, and that provider-side billing falls by something like half.

Prices, $250–400B. Hospitals charge commercial insurers roughly two and a half times what Medicare pays for identical services, and physician fees are higher in the commercial market too. Moving everyone to a single negotiated schedule brings commercial prices down toward the public rate. The range does not assume commercial prices fall to today's Medicare rate, because the plan holds physician take-home flat at the transition and lets it converge slowly, and because hospital global budgets are set to keep hospitals open, not to cut them to the bone.

Drugs, $150–250B. Measured against what payers actually pay after rebates, not against list prices, which are the fiction the pharmacy benefit managers exist to exploit. The saving comes from one public price across the whole market, from generic competition on prize-fund drugs, and from ending the PBM spread. The prize fund's own cost, $100–150 billion a year, is netted inside this line.

Medicare Advantage, $40–60B. Congress's advisers estimate the plans are paid on the order of 20 percent more than traditional Medicare would cost for the same people, around $84 billion in 2025. The plan counts only the part of that which comes from coding and selection, because the 33 million people involved move to a richer benefit rather than a cheaper one, and the money that was buying them dental and vision is now buying everyone dental and vision.

Avoidable acute care, $50–100B. Free primary care and a primary-care workforce at something nearer the peer-country ratio should reduce the emergency admissions and late-stage rescue that a system without a foundation produces. This is the softest savings line, and it is kept small.

What the spending lines assume

Operating the new capacity, $150–300B. This is the largest uncertain item in the plan and the largest single line in it. A construction program of $75–100 billion a year builds a great deal, and staffing and running what it builds costs more than building it, every year, permanently. Hill-Burton's central failure was building hospitals with no operating model (Appendix A), and the plan will not repeat it, which means the budget has to carry the operating cost of every reopened rural hospital, every new health center, every psychiatric bed, and every long-term care place.

Long-term care, $200–300B. Long-term services and supports, at home and in facilities, are the largest gap in American coverage. Medicare does not cover them, Medicaid covers them only after a family has spent down its assets, and most of the care is delivered unpaid by relatives. The line includes the caregiver allowance, the assessor corps, and the paid benefit that goes live in year four to five. It is large because the need is large and the plan does not pretend otherwise.

Induced use, $100–200B. Moving roughly 165 million already-insured Americans from real deductibles to zero is a larger demand shock than covering the uninsured. The Oregon experiment (Appendix K) is the only randomized evidence on what happens when people gain free coverage, and it found use rose by about a quarter to a third. It would be easy to budget this at nothing while arguing that America is one of the thinnest-provisioned systems in the developed world. If that diagnosis is right, unmet need is large and free care will surface it. That is the plan working, and the budget has to cover it.

Covering the uninsured and underinsured, $100–150B. About 26 million people have no coverage and tens of millions more have coverage with deductibles they cannot meet. This is the line every previous plan was about, and here it is the fourth largest.

Dental, vision, and hearing, $75–100B. Categories Medicare has never covered, for everyone.

The capital program, $75–100B a year for 10 years. One to two cents of every dollar the country spends on health care.

Mental health and addiction, $50–75B. Capacity, above all: psychiatric beds, crisis services, addiction treatment, and the clinicians to staff them. Capacity is the binding constraint here and the least fixable in the near term.

The Health Workers Transition Guarantee, $40–60B, front-loaded. Wage replacement, wage insurance, retraining, and pensions for the hundreds of thousands of people whose jobs the plan eliminates. The line is high in years one through five and falls to nearly nothing by year 10.

The pipelines, public health, and the rest. Residencies, tuition, and new schools at $30–40B; the nursing and allied pipeline at $15–25B; a public health rebuild at $20–40B, since public health is not the same thing as medical care and has been starved for longer; and the no-fault injury compensation system that replaces malpractice, together with the national health record, at $15–30B.

The costs that land once

Some costs are not in the annual net above because they happen once, or only during the transition.

• The medical debt fairness refund: $100–250B. The largest one-off item. See below.
• Canceling the debt itself: low billions. Medical debt trades on the secondary market at pennies on the dollar, so buying and retiring a face value in the hundreds of billions costs a small fraction of that.
• Paying transition-window provider receivables rather than forgiving them: $30–60B. When the payer changes, providers hold claims against the old payers. Paying them, rather than leaving providers to collect from insurers in run-off, is what prevents a collapse in hospital cash flow at cutover.
• Premium Guarantee reinsurance: $40–80B a year during the transition, declining to nothing. While private insurers still exist and the government is taking liabilities off their books, the plan reinsures the guarantee that no plan prices above the prior year.

The medical debt refund, costed three ways

About 41 percent of American adults carry medical or dental debt, roughly 106 million people. The plan cancels it, and refunds payments made in the seven years before enactment, dollar for dollar, capped at $10,000 per person. The design choices are what keep the cost bounded.

Version	Rough one-off cost	Why
Cancellation alone	low billions	Debt bought on the secondary market at pennies on the dollar
Recommended: 7-year refund, dollar-for-dollar, $10,000 cap	$100–250B	Bounded window, proportional to what was paid, capped, take-up well under 100%
Lifetime lookback, flat $10,000 per person	$1.4–1.8 trillion	If 41% of adults hold medical debt today, the share who have ever paid some down is plausibly 55–70% of about 258 million adults, call it 145–180 million people, at $10,000 each

Seven years is not arbitrary. It matches the period for which the Fair Credit Reporting Act allows a collection account to stay on a credit report, so it is also the window in which payment records reliably exist. A lifetime lookback cannot be documented and collapses into self-attestation, which is both unaffordable and unfair. Seven years reaches the people whose grievance is live, those still paying and those who just finished. Wherever records exist, in active payment plans, collection accounts, and provider receivables, the refund is paid automatically with no form, which costs less to administer and makes the relief legible. An application process is reserved for older self-financed debt that no record captures.

The liability with no number: contract damages

Under the Supreme Court's 1996 decision in United States v. Winstar, when Congress changes the law in a way that breaches the government's own contracts, the statute stands but the Treasury pays contract damages to the other party. The case arose from the savings-and-loan crisis, when Congress changed accounting rules that regulators had contractually promised thrifts they could rely on, and the thrifts recovered. The principle is general: the government can legislate away a contract, but it pays for doing so.

This plan abrogates at least three sets of contracts: the Medicare Advantage contracts covering 33 million enrollees, the Medicare provider agreements with every hospital and physician that bills the program, and the Medicare Administrative Contractor agreements under which private companies process traditional Medicare's claims today. The exposure runs through the Court of Federal Claims and has no number against it yet.

It is mitigated three ways. Wherever possible, contracts are ended prospectively under their own terms, at renewal or on the notice period they already contain, rather than abrogated. Where the statute must abrogate, it includes an express damages-limiting provision, which Congress can do because it writes the terms on which it can be sued. And it substitutes a defined wind-down payment schedule for the lost profits and costs the other party would otherwise claim, so that the exposure is a known number paid on a known schedule rather than a decade of litigation. This liability sits alongside the other unpriced one, the royalties owed on any patent used under Section 1498 (Appendix E); both run through the same court, and neither has been tested.

Who pays

All funding flows through a single trust fund, filled by dedicated revenue rather than an annual appropriation, on the model of Social Security. The revenue is the money employers and households already spend on health insurance, redirected. Employers pay a payroll contribution in place of the premiums they pay today, and households pay taxes in place of premiums, deductibles, and copays. The household calculator, which publishes during the 2028 campaign, is what turns "roughly what America already pays" into a number each family can look up about itself. Until it exists, every household figure in this plan is illustrative, and the text says so.