A Health Care System for America: The Plan

This document is the plan: what we will do, in what order, and why. It is written to be read on its own. The background a reader needs to judge it, the history of the programs it revives, the laws it changes, the precedents it relies on, and the full cost arithmetic, is in a set of implementation appendices, one per topic. The plan links to them where they apply.

The whole plan on one page

America's health care crisis is driven in large part by a severe shortage of workers and physical infrastructure. Every major Democratic health plan of the last 30 years, both proposed and enacted, has paid for care without building the clinics or training the staff to provide it. The Affordable Care Act insured 20 million people, but rural hospitals kept closing because coverage alone did nothing to fix funding and staffing gaps.

Building hospitals takes years and training doctors takes a decade, but the dysfunction that makes an insured middle-class American hate the health care system is mostly rules and money, and rules and money can move in year one.

Our plan:

1. Launches Medicare for All. Every American will be enrolled in Medicare, which will assume the role of a single public payer with all health care fees negotiated in the open. Hospitals are paid by a fixed budget, not by claim, and all drugs are bought at the same public price.
2. Builds the capacity. A 10-year federal capital program to build and reopen hospitals, clinics, maternity units, psychiatric beds, dialysis centers, dental facilities, and long-term care, placed where people live, including the communities the market abandoned. The public funds it out of a capital budget kept separate from what hospitals are paid to operate, so they no longer expand by chasing profitable services.
3. Opens the professions. Break the artificial cap on doctors, increase the number of medical residencies, make medical school free in exchange for service, and license qualified foreign-trained physicians. The plan also breaks the nursing bottleneck by giving training programs the resources they need to train every qualified applicant, and requires safe staffing ratios where nurses work.
4. Reforms the providers. Providers may stay private (that is what Japan and South Korea do, and Japan outlives and outperforms the United States on every measure at a third of the cost) but as a condition of billing Medicare, institutional providers may not pay out profits to shareholders and may not turn away public patients. They may not set their own prices. We will break up the private-equity-backed consolidations of hospitals and physician practices that raise prices for consumers. We will build public pharmaceutical manufacturing and pay generous prizes for new drugs and put the patents in the public domain.
5. Winds down the insurance industry. Some major insurers have grown far beyond insurance; UnitedHealth alone employs or contracts one in 10 American doctors, so the conglomerates are split apart. The insurance business closes and the pharmacy benefit managers are abolished, since a single public payer buying at a public price leaves them nothing to do. The doctors and clinics they own become public and community providers rather than closing. Everyone who loses a job gets full wage replacement, paid retraining, and first refusal on the care jobs this same bill creates.
6. Cancels medical debt, and pays back the people who paid. Medical debt is sold to collectors at pennies on the dollar, so the government buys all of it and retires it for a few billion dollars, one of the cheapest measures in the plan, on the day the law is signed. Collection and garnishment stop the same day. And anyone who paid off medical debt in the seven years before enactment is refunded, dollar for dollar, up to $10,000.

Everyone is covered, from birth, automatically. You choose any doctor and any hospital in the country. What the public pays for is decided in the open and widely published. What it doesn't pay for, you may always buy, and if you would rather not wait for a covered service, you may pay to be seen sooner. Nobody is ever forbidden care, they are only told what the public system covers.

On the day the new legislation is signed, medical debt is canceled, collectors and garnishment are stopped, and those who already paid theirs off are refunded up to $10,000. From that same day, and for as long as private insurers still exist, an insurance claim is approved automatically if the insurer does not answer within a set deadline, care is paid for by the insurer while any appeal runs, a permanent condition is authorized permanently, and surprise billing ends.

Within the first year, chronic-disease drugs become free at the counter for everyone in America, through the federal supply chain that already delivers drugs to the VA and the Indian Health Service. Family members already doing care work begin receiving direct cash payments. Primary care becomes free, out-of-pocket costs are capped at $1,000 a person while private coverage is still in place, and glasses and hearing aids are covered. Every American gets access to one national search portal that finds the nearest doctor with an opening and books the appointment. None of this requires anyone to change health plans or doctors, or to fill out a new application.

The plan costs roughly what America already pays today, but redirects the money into coverage for everyone, with long-term care, dental and mental health included, plus the infrastructure buildout.

The Problem

The American government alone already spends $2.56 trillion a year on health care, which is $7,526 of public money for every person in the country. That is more than many other wealthy nations spend per person on their entire health systems, public and private combined, including Spain ($4,935), Italy ($4,866), South Korea ($4,798), Israel ($4,033), Portugal ($4,679), and the United Kingdom ($6,365). Japan spends $5,365 per person for what is widely considered one of the best health systems on the planet.

American taxpayers already pay enough to support a universal health system. They just don't get one.

Instead, health care consumers are forced to pay even more, roughly $2.12 trillion per year in premiums, deductibles, copays, and out-of-pocket expenses. Those two figures together come to $4.7 trillion. The rest of the roughly $6.0 trillion the United States will spend on health care in 2026, 19% of GDP, is mostly the employers' share of insurance premiums. The excess money isn't going into extra care. Americans see doctors less often than people in peer countries and spend fewer days in hospital. The excess goes into three places:

• Prices. Hospitals charge commercial insurers roughly 2.5× what they charge Medicare for identical services. Same MRI, five to 10 times the price of France's. Same insulin, many times the price of Canada's.
• Billing. America runs a private claims-adjudication industry that no other country has. Estimates of administrative cost run from 15% to 30% of all spending; billing-and-insurance-related costs alone are put around $500 billion a year. Every dollar of it is a dollar that treats nobody.
• A missing foundation. Roughly a third of American physicians are in primary care against half or more in peer countries, so cheap prevention doesn't happen and expensive rescue does.

Altogether, Americans pay more for health care that is worse than that of any other affluent nation.

From the live comparative data:

	United States	How the United States ranks
Total spending per person, public and private	$13,473	35th of 35 advanced nations, the most expensive
Life expectancy	78.9 years	30th of 35
Healthy life expectancy	63.9 years	34th of 35
Years lived in poor health	12.5	34th of 35
Infant mortality	5.5 / 1,000	33rd of 35
Maternal mortality	17 / 100,000	34th of 35
Public share of hospital beds	21.1%	32nd of 33

Closing these gaps will require, among other things, a mass mobilization of skilled health care workers, and here too the country is lagging behind. The United States has about 2.6 practicing physicians per 1,000 people against an OECD average of 3.7, a gap of roughly 370,000 doctors. Medicare's funding of residency slots has been frozen at 1996 levels since 1997. Nursing schools turn away tens of thousands of qualified applicants every year because they lack faculty and clinical placements. More than 100 rural hospitals have closed since 2010, and over a third of US counties have no obstetric care at all.

Build the capacity

America has built health care before, deliberately and at national scale. In 1946 Harry Truman signed the Hill-Burton Act. It surveyed every state for shortages of hospital beds, then paid federal grants against a local match to build them, on condition that the facility serve everyone in the community regardless of ability to pay. Over its life it built or modernized roughly 6,800 facilities and half a million beds, and it is the reason most mid-century American communities got a hospital at all. It was signed by a Democrat and sustained by Republicans, and it was allowed to lapse in the early 1970s when the country switched to running health care as a market. The capacity has been closing ever since. The full story, and what its design got right and wrong, is in Appendix A.

The National Health Facilities Program is modeled on Hill-Burton. It is authorized to award roughly $75–100 billion a year for 10 years to support hospital upgrade and construction projects nationwide, which is between one and two cents of every dollar the country already spends on health care.

The program will include:

• A national capacity survey first, going county by county, exactly as Hill-Burton began. It will identify gaps across the health sector, from maternity units and ERs to dental chairs and behavioral health offices. The results will be published online and updated throughout the program.
• Reopen or replace closed public and community hospitals. Where a facility was closed for financial reasons, not clinical ones, which is most of them, reopen it under public or community-nonprofit ownership with a guaranteed budget that makes low volume survivable.
• Community health centers as the spine of primary care. The Federally Qualified Health Center model exists, serves 30 million people today, and outperforms on cost. The program will put a health center within reach of every American, with dental and behavioral health inside the same building.
• Funding provided by the public, not hospital budgets. In many well-run systems, hospitals don't fund expansion out of operating margins. Public funding will ensure expansions go where there is the most need.
• Every facility built with public capital is publicly or community owned, with an open-books requirement and a board that includes the people it serves.

Doctors

America does not have enough doctors, and the ones it has are in the wrong places and the wrong specialties. That is not an accident of the market. It is the product of four bottlenecks, each of them written into law or run by a private body, and each of them fixable. Appendix B explains all four in detail. In brief:

• Residency positions. Every doctor has to train for years inside a hospital after medical school, and Medicare, which pays for most of that training, froze the number of positions it funds at each hospital's 1996 headcount. Congress has added about 1,200 slots since, against a need in the tens of thousands. A private accreditor, the ACGME, decides which hospitals may train residents at all and must approve any permanent increase.
• Immigration. About one in six new residents each year is a foreign national on a visa that requires them to leave the country for two years when training ends. The main exception, the Conrad 30 waiver, has been capped at 30 physicians per state for two decades. And a physician who arrives fully trained cannot, in most states, get a license without repeating an American residency.
• Medical school seats. Enrollment has grown, but universal coverage needs more, and the accreditors require notice of large increases in class size.
• The license. There is no national medical license. About 70 state boards issue licenses that stop at the state line, so a surplus in one state does nothing for a shortage in the next.

Training more doctors

Pay for the residencies directly. We will create a National Residency Fund, a permanent appropriation separate from the Medicare trust funds, that pays a set national amount per resident to the institution doing the training. The goal is 15,000 to 20,000 new funded positions phased in over a decade, with the law directing them toward the fields facing the most acute shortages, such as primary care and psychiatry, and toward communities with documented shortages. The places with the most room to grow are the smaller and less affluent community and safety-net hospitals, and the program funds the faculty, administrative offices, curriculum development, and accreditation work that a new program needs. The Teaching Health Center program, which already trains around 1,100 residents primarily in community health centers, is made permanent and scaled to a third of all new primary care positions.

Work with the accreditors. The ACGME must approve a permanent increase in a residency program's size, and the government cannot overturn its decisions. The program's first approach is to work with it. Should it resist or move too slowly, Medicare's regulations could allow the Secretary of Health and Human Services to recognize an additional accrediting organization, and Congress would condition federal funds on states licensing graduates of any federally recognized program. A national federal license, recognized in every state for physicians practicing in shortage areas under federal programs, closes the rest of the gap. The VA has operated this way.

Expand medical schools where the government already operates. The program will fund the expansion or building of public medical and osteopathic schools sited by shortage and attached to state universities, public hospital systems, and VA medical centers, working with the accreditors to grow class sizes at a pace the schools can resource. Tuition at a public medical or osteopathic school is paid in full for any student who commits to a set number of years in a shortage area or an under-supplied specialty. The average indebted medical graduate now leaves with debt in the low-to-mid six figures, and that debt is one of the reasons so many choose the high-paying specialties over primary care and psychiatry. Removing it removes the financial argument against the fields the country is shortest of.

Open the system for foreign-trained physicians. The program builds a national assessment and bridge program for physicians trained abroad: a standard evaluation, targeted retraining where it is needed, a period of supervised practice, then a full license. Israel absorbed more than 12,000 Soviet-trained physicians this way in the 1990s, with real attrition at the examination stage, which is a reason to design the assessment carefully. On the immigration side, the program exempts physicians serving designated shortage areas from the employment-based green card caps, including the per-country cap that leaves Indian physicians waiting decades. It raises or eliminates the Conrad 30 limit, makes the J-1 waiver automatic for anyone committing to three years in a shortage area, and grants permanent status when that commitment is served. And it ties residency money to state action: a state that enacts a qualifying pathway for foreign-trained physicians unlocks additional residency funding for its hospitals.

Doctors where they are needed most

Physician shortages are worst in rural counties and in poor urban neighborhoods, and both need their own workforce strategy.

Recruit locally and train locally. Doctors are more likely to stay in a rural community or an underserved city neighborhood long-term if they grew up in one. So this plan funds residency programs physically located in those places, and gives admissions preference to applicants who come from them. This is also the most direct route to increasing the number of Black and Hispanic physicians.

A much larger National Health Service Corps. The tuition guarantee above opens a public medical school to anyone willing to serve. The Corps is the sharper instrument, aimed at the hardest places to staff. It recruits the graduate who has already trained, it is expanded substantially, and it now pays a competitive salary on top of covering tuition.

Substitute physicians as a public service. Practices and clinics currently arrange temporary coverage through private staffing agencies, often at great expense. This program creates a federal relief corps of salaried physicians whose job is coverage: parental leave, illness, vacation, and vacancies between hires. Coverage is free to sites in designated shortage areas and available at cost elsewhere. Corps physicians hold federal licensure recognized in every state and are covered under the Federal Tort Claims Act, so a doctor can be dispatched across state lines without a licensing delay.

A route back for clinicians who left. Tens of thousands of doctors and nurses hold lapsed licenses, and most states offer no defined path back. The program funds a refresher and supervised-practice bridge, pays a stipend during it, and requires every participating state to publish one reinstatement route with a fixed timetable. These are clinicians who are already trained, which is why they arrive in months rather than years.

Telehealth as a covered service, paid the same as an in-person visit. A remote visit adds capacity without a building and reaches a rural county years before anything can be built there. Insurers have paid less for a remote visit than for the same visit in person, so the program pays both at the same rate, and it preempts state licensure barriers for remote care on the same footing as the federal licensure the relief corps carries.

Malpractice reform

Malpractice is the system by which a patient harmed by medical care sues the doctor or hospital responsible. The direct cost to the system is modest, but the weight on clinicians is not.

The government takes on malpractice liability for any provider in the public system, so the premium, which can run tens of thousands of dollars a year per doctor, disappears from a practice's costs. Patients harmed by treatment apply to a public body for compensation instead of suing. They only have to show that the treatment caused the harm, not that anyone was negligent, which means more of them are compensated and they are compensated faster. New Zealand and Sweden run broadly similar systems.

Removing the lawsuit does not remove accountability. Licensing boards keep their power to investigate, restrict, and revoke, and the compensation claims themselves become a live record of which clinicians harm patients repeatedly, which is more than the current system produces, since most malpractice suits settle privately.

Nurses and the rest of the workforce

In 2025, nursing schools rejected 93,176 qualified applications, nearly 17,000 of them to the graduate programs that produce nursing faculty. The schools were not short of students. They were short of faculty, of experienced nurses to supervise students on the ward, of clinical sites, and of classrooms. Every fix below targets one of those. The background is in Appendix B.

Pay the preceptors. A preceptor is the experienced nurse who supervises a student on the ward. That teaching is usually unpaid and added on top of a regular shift. This program pays a per-student clinical education fee to the hosting facility and a cash stipend to the preceptor. This fixes the same bottleneck for nurse practitioner training.

Raise the simulation ceiling. National research found that replacing up to half of traditional clinical hours with high-quality simulation produces the same learning outcomes. Many state boards cap simulation at that same level. This program funds simulation centers on the condition that the state board raises its cap to match the evidence, which expands training capacity without finding a single new hospital ward.

Coordinate clinical placements statewide. Right now many nursing schools negotiate their own placements. This program funds a placement exchange in every participating state: a registry of available clinical slots by unit and specialty, and a scheduling system.

Pay nursing faculty what practice pays. A nurse practitioner earns substantially more in practice than in a nursing school, which is one reason faculty positions go unfilled and unfilled positions cap enrollment. This program funds faculty salary supplements to close the gap, tied to programs that expand enrollment, and pays for graduate education for nurses who commit to teaching.

Free tuition for nursing and the other fields with real shortages. Full tuition at public institutions for nursing and related fields such as respiratory therapy, radiologic technology, clinical laboratory science, surgical technology, and behavioral health.

National safe staffing ratios. California wrote the first statewide nurse-to-patient ratios into law in 1999, and the evidence shows they improved both patient survival and nurse retention. The program sets enforceable minimum ratios nationwide as a condition of Medicare participation, with funded transition time for hospitals that need to hire before they can comply.

A wage floor and career ladder for home and long-term care workers. Home health and personal care aides are among the fastest-growing occupations in the country, and they largely pay a poverty wage, so turnover is high. This program sets a federal wage floor for direct care work funded by Medicaid and raises federal matching payments to cover it. It also builds a career ladder, with paid training, recognized credentials, and higher pay at each step from personal care aide through certified nursing assistant and into licensed practical nursing, so that direct care becomes an entry point into the health care industry. That ladder is also a supply strategy for the nursing shortage, drawing from people already doing care work in the communities that need nurses most.

Let trained clinicians work to the full extent of their training. In much of the country, nurse practitioners, physician assistants, and certified nurse-midwives are still required to hold a supervision agreement with a physician, and pharmacists are barred from independently prescribing for minor conditions they are trained to treat. This program removes those restrictions using the same three federal levers throughout: it pays the same rate whoever delivers the service, it preempts contrary state scope-of-practice law for clinicians in the national program, and it conditions federal funding on states falling in line. This is the fastest capacity in the plan, because every one of these clinicians is already trained, already licensed, and already working.

Universal Coverage: one payer, one price

This plan will expand Medicare to create a single public insurance program covering every American from birth. There will be no premiums, no copays, and no private insurance companies denying coverage.

Launching the program requires one large piece of legislation, passed by a simple majority once the filibuster is gone, which the final section of this plan explains. Its features are these:

End duplicate private insurance. The law has to prohibit private insurance from selling coverage that duplicates the public benefit. Without that clause, we risk creating a two-tier system where the well-insured opt out of the public system. What people may still buy, including the right to pay to be seen sooner, is set out in the section on coverage and waiting times below.

End employer-based coverage. About half of Americans get insurance through a job, under a 1974 law called ERISA that governs employer benefit plans. Prohibiting any plan from duplicating the national benefit leaves employer health plans with nothing to cover, and ERISA's health provisions are then repealed as cleanup, along with the Affordable Care Act's employer mandate and reporting requirements. Union health funds, built through decades of bargaining in which workers traded wages for benefits, continue as supplemental coverage for anything the national program does not include. The employers' former health contributions convert into wages for the workers.

What is covered. The bill will write the benefit categories into law: hospital care, physician and clinician services, emergency care, prescription drugs, laboratory and imaging, maternity and newborn care, mental health and substance use treatment, rehabilitation, medical equipment and devices, and preventive care. It will also cover categories Medicare has never included, specifically dental, vision, hearing, and long-term services and supports, including care at home.

Fold in the existing programs. Medicaid, CHIP, and the Affordable Care Act's insurance subsidies are absorbed into the national program and cease to exist as separate systems. That ends the coverage gap in states that refused the Medicaid expansion, and it ends the instability in which people lose and regain coverage as their income fluctuates across an eligibility line. Federal employee health benefits and TRICARE, the military health plan, are absorbed as well. The Veterans Health Administration and the Indian Health Service continue to operate as they do now, because both are direct providers of care with specific obligations behind them; the national program pays for care those systems do not deliver, so a veteran or a tribal member can use either without losing access to the other.

Create the payment architecture. Hospitals move from billing procedure by procedure to an annual budget, and doctors and other clinicians are paid from a single national fee schedule, so the price of a visit no longer depends on which insurer the patient carries.

Pay for it. All funding flows through a single trust fund, filled by dedicated revenue, not an annual appropriation, similar to the way Social Security already works. The revenue comes from what employers and households already spend on health insurance, redirected into public financing. Employers pay a payroll contribution and households pay taxes, in place of premiums, deductibles, and copays.

Handle the transition. The program phases in over several years, because hospitals and health care workers will need time to adjust and the new payment systems have to be built and tested before the entire country depends on them. As the law eliminates hundreds of thousands of jobs across insurance, pharmacy benefit management, and medical billing, the displaced workers will get wage replacement, pension protection, and paid retraining.

How prices get set

Today, the price Medicare pays for every medical service in the country is built on a score of how much work the service involves, and those scores are recommended by a committee of the American Medical Association that surveys its own members. The government adopts about eight or nine in 10 of its recommendations because it has no data of its own to check them against. The result is a schedule that overpays procedures and underpays the primary care visit. How that system came to be, and how Japan reprices its entire schedule every two years from a government survey, is in Appendix C.

Our system has four parts.

First, we fund the survey that sets the scores. Congress will launch a standing government survey of how long procedures actually take and how much skill they demand, run by CMS, not by the doctors being paid for the service. Teams across the country will observe procedures in a representative sample of hospitals and clinics, time them, and publish the findings.

Second, we put the scores on a deadline. Every relative value expires on a fixed two-year cycle and has to be rebuilt from the new public data rather than carried forward, so no distorted price can slide through the system.

Third, we publish everything: the survey data, the sample, the methodology, and the reasoning behind every value, released online before the new scores take effect.

Fourth, the schedule is negotiated in public. The survey settles what each service is worth relative to every other one. What a point is worth in dollars, the number that decides both what a doctor earns and what the country spends, is set on the same two-year cycle, for the whole country, in open session between the payer and the organized bodies that represent doctors and hospitals, inside a national budget for what the system will spend. There is one price for a service, whoever is paying and whoever is treated, and the argument about what it should be happens on the record. Japan has run this way for decades.

How hospitals get paid

Instead of being paid per claim, a hospital receives a negotiated annual budget, paid monthly, adjusted for population and case mix. This makes small and rural hospitals viable, because revenue no longer rises and falls with patient volume. It also kills the billing industry at its source, since a hospital paid a monthly budget has no use for a sizable revenue-cycle department. Maryland has run all-payer hospital global budgets since 2014, which is the American proof that this is administratively possible here (see Appendix C).

What happens to physician incomes

American physicians earn more than their peers in every comparable country, and this plan will not enforce immediate or draconian pay cuts. Instead, the program holds physician take-home flat in nominal terms at the transition and lets real incomes drift down slowly over a decade as supply expands. In exchange, a physician gets their billing overhead eliminated, their malpractice premiums replaced by public indemnity, freedom from insurance companies pre-approving coverage, and patients who can actually afford what they prescribe. For most working physicians that is a raise in everything but the number. For the specialties at the very top it is a slow, announced, decade-long convergence toward the rest of the profession.

Drugs: pay for the invention, then free the medicine

America pays more for prescription drugs than any other high-income nation. In many cases, the research that produces these expensive medicines is funded by the public itself. One study traced NIH funding behind every one of the 210 drugs approved between 2010 and 2016. We fund the research, hand the patent to a company, and then buy the product back at monopoly prices.

The proposal

Congress will create a Health Innovation Prize Fund. When a company develops a new medicine, the public pays it a large cash prize set in advance, sized to how much good the drug actually does for patients. The company takes the money and gives up the patent, so anyone in the world can manufacture the drug immediately and for free.

The prize targets the medicines the current system is worst at producing, such as new antibiotics, vaccines, treatments for rare diseases, and drugs for conditions concentrated in poor countries. Any medicine where the need is enormous and the profit is small.

Today a company earns its money by being the only one allowed to make a drug for 20 years, which means the reward comes from controlling access, not from the medicine itself. The prize pays for the medicine and lets everyone make it.

• Fund size: on the order of $100–150 billion a year, against roughly $700 billion America currently spends on drugs at list price. Even paying full prizes and buying generics, total drug spending falls by hundreds of billions a year.
• Pay on delivered health benefit, not on sales. A cure for a disease of the poor pays as well as a lifestyle drug for the rich, reversing the single worst distortion in pharmaceutical research.
• Priority premiums for antibiotics, vaccines, tuberculosis, and every neglected disease the market has never served.

While it may sound like a departure, the United States already has a track record here. During the pandemic, Operation Warp Speed promised to buy vaccines that did not yet exist, offered billions of dollars, and had a working shot in about eight months.

Drugs already under patent

The prize fund pays for medicines not yet invented. It does nothing for a drug on the market today whose patent runs another 15 years.

Most of those drugs get cheaper on their own once Medicare takes over price-setting. A manufacturer that refuses the public price is refusing the American market, and almost none will. The exception is a drug with no substitute, where the manufacturer can hold out because the patient cannot wait; Gilead did this with its hepatitis C cure and arguably Vertex with the only medicine that treats cystic fibrosis at its source. The other failure is a shortage, like the 2023 collapse of the cisplatin supply when a single Indian plant went offline, which no patent caused and no price could fix. What was missing was a factory.

So the program keeps a last resort. Where a manufacturer refuses a price the schedule can sustain, or cannot supply the country, the government authorizes someone else to make the drug and pays the patent holder afterward. The federal government has held that power for over a century, used it routinely through the 1960s, and got Bayer to cut its price for ciprofloxacin nearly in half in 2001 merely by mentioning it. But the courts have read it as not covering drugs the government pays for at a pharmacy counter, and biologics, the costliest medicines, carry a separate 12-year exclusivity that no patent authority reaches. The bill closes both gaps. What the authority is, what the statute has to say, what using it costs, and why international law does not forbid it, are in Appendix E.

The pharmacy counter

The pharmacy benefit managers are abolished, but not on a Tuesday. These companies run the payment system at every pharmacy counter in the country: when a prescription is handed over, something confirms coverage in under a second, typically checks the drug against everything else the patient is taking, and moves the payment. Even a short outage would endanger millions. So the existing system is taken over rather than replaced. It runs as a regulated utility on a fixed transfer date, every prescription presented in the first 180 days is filled and paid with eligibility reconciled afterward, and the staff and the claims history move with the system. What a PBM is, why the payment plumbing sits inside them, and how the 2006 launch of Medicare Part D failed at exactly this point, are in Appendix F.

Public manufacturing

Unlike Cuba, China, Brazil, Thailand, Indonesia, and Bangladesh, the United States has no state-owned drug manufacturer and no large-scale public vaccine plant. Public manufacturing is what makes the rest of this plan enforceable. Setting a public price only works if the government can walk away from a manufacturer who refuses it, and authorizing production only helps if somebody can actually produce the drug afterward.

Congress created BARDA in 2006 to prepare the country for pandemics and bioterrorism. It funds companies to develop vaccines and treatments, stockpiles the results, and did much of the work behind Operation Warp Speed, but it is not known to own any factories and depends entirely on private contractors. This plan expands BARDA's funding and mandate to build and operate its own plants, making the cheap everyday drugs that hospitals run out of, along with the medicines the public paid to develop. The precedents, American and foreign, are in Appendix E.

The record and the public app

One national health record that follows the patient, and an app for finding a doctor and booking an appointment that works as easily as calling an Uber.

• One national health record, owned by the patient. Every visit, prescription, scan, and lab result in one place, portable and permanent. Estonia has run this since 2008 and nearly all of its prescriptions are electronic. Denmark, Israel, and India have working national systems too.
• You can see who opened your record. Every clinician who looks at your file is logged, and the log is visible to you, permanently. Estonia has run its national record this way for years, and the openness is what makes a single record politically survivable. The answer to privacy is that you can watch, not that the data sits behind a wall.
• An open interface, required as a condition of payment. The government builds a solid reference app and anyone is free to build a better one. Companies compete on having the best software.
• Appointment availability published openly. Booking a physician will have the same convenience as hailing a car or making a reservation. The app will include every health care provider in the country.

What's covered, and what happens if you have to wait

Every health system in the world rations. The United States rations more harshly than most of them and far less openly: by price, by deductible, by network, by prior authorization, and by claim denial, with the decision made by an employee of a company whose profit rises when the answer is no, with no published reasoning and an appeals process most people cannot afford to use.

This plan does the same job in the open. A public body decides what the system pays for, publishes its reasoning, and takes public comment. Almost everything is covered. What is not covered, you may still buy. And if a covered service makes you wait too long, the system owes you treatment somewhere else at its own expense. How Britain, Germany, Japan, and Denmark run the same machinery is in Appendix D.

What is covered

• Start from inclusion. Everything medically established is covered: hospital care, physicians, emergency care, mental health, addiction treatment, maternity, dental, vision, hearing, prescription drugs, rehabilitation, medical devices, and long-term care. The schedule's job is to exclude what does not work, not to ration what does.
• A published national benefits schedule. An expert body decides what the system pays for, meets in public, publishes its reasoning and its cost-effectiveness thresholds, and takes comment before deciding. Britain, Germany, and Japan all have one, and all of them are widely considered more transparent than an insurance company's claims department.
• Reproductive health care is covered in full, including abortion. That requires repealing the Hyde Amendment, the longstanding rider barring federal funds from paying for most abortions.
• Immigration status is not a test. The plan covers everyone physically present in the United States.
• A clinician override for the individual case. A treating physician can authorize a service the schedule does not cover when a patient's circumstances require it. The schedule governs the general case. The doctor governs the specific one.

What you can buy

Anything the public schedule does not cover, you may always buy, with cash or with private insurance. And for anything it does cover, you may pay to be seen sooner, on the terms set out below. Two rules keep either from hollowing out the public system:

• Private coverage is supplementary, never substitutive. Everyone is in the public system and pays for it regardless of what else they buy. Private insurance covers only what the public schedule excludes, and the access fee for being seen sooner. It can never become a way out of paying in.
• Private facilities pay a training levy when they employ publicly trained clinicians, so the private tier pays for the workforce it draws on.

What happens if you wait

The program will work with independent experts to set a maximum wait for every service, the way England guarantees 18 weeks from referral to treatment and Denmark 30 days. Urgent cases get days, routine ones get weeks, and the number is published for each. When no local facility can provide the service before the deadline, the patient is automatically entitled to treatment at any other participating facility nationwide at public expense, paid from a national pool funded separately from any hospital's own budget.

Paying to be seen sooner

Most universal systems have a queue for routine care, and in its early years the American one will be long, because coverage arrives in year one and the clinics and clinicians arrive over the decade after. This plan does not pretend otherwise. Nor does it pretend that the people who today get a specialist appointment in a week will accept waiting three months for one. If they are forced to, they will kill the plan, as the insurance industry and its allies killed every plan before it.

So the plan makes a settlement, and states it plainly. Everyone is covered, everyone pays in, and every covered service is free at the point of use, with a published maximum wait and a guarantee behind it. Anyone who would rather not wait may pay to be seen sooner, with cash or with supplemental insurance, on roughly the schedule they get care today. For the tens of millions of people who have no coverage now, or coverage they cannot afford to use, the plan is a transformation: they are covered, and for routine care they may have to wait. For the people with good insurance now, the plan preserves what they have, the doctor, the hospital, and the speed, at a fraction of what they pay for it today. Nobody is made to wait who is not waiting already, nobody is uncovered who was covered before, and everyone pays less. That is the deal, and it is the only deal the country's most politically powerful class will accept.

How it works:

• The public payer pays the same either way. An expedited visit or procedure is billed to the public payer at the schedule price, exactly as if the patient had waited. The patient, or their supplemental insurer, pays a published access fee on top. The public spends nothing extra, and the fast patient pays once for the care and once for the speed, never twice for the care.
• The fee is published, like every other price. On the national price API, in advance, per provider and per service. No provider may charge an access fee it did not publish.
• Every access fee pays a levy into the capacity fund. A fixed share of every fee goes to the beds, clinics, and training that shorten the public queue. The people buying their way forward are funding the capacity that will make buying your way forward unnecessary.
• A provider selling speed must keep doing its public work. The danger in any paid lane is that it makes the public queue longer rather than shorter: if private patients pay more, surgeons' hours migrate to them, public waits grow, the paid lane becomes more valuable, and more hours follow. So a provider's public volume in each service line may not fall below its share in the year before it began selling expedited access, measured automatically from the appointment feed every provider must publish. A provider that falls below its floor loses the right to sell expedited access in that service line until it is back above it.
• Speed is for elective and routine care only. Emergency and urgent care is triaged by clinical need, as it is now, and nobody can buy a place ahead of a sicker patient. Where a treating physician certifies that a wait would cause harm, the case is urgent, the guarantee's shorter clock applies, and there is nothing to pay.
• The lane shrinks as the queue does. Nothing closes the expedited lane by decree. As the capacity program delivers and the public system meets its waiting-time guarantee for a service, there is nothing left to buy in that service and the lane withers on its own. The waiting-time data, published by facility and service line, shows where that has happened and where it has not.

Nobody in America will ever be stopped from getting care they want to buy, and nobody will ever again go bankrupt getting care they need.

The insurance industry: what happens to the companies, and to the people

A single payer eliminates jobs across insurance and medical billing administration. This plan provides a smooth and just transition for every affected worker, and it deals with an industry that has changed shape in the years since Medicare for All was last debated in Congress in 2019.

The large insurers have spent the last decade buying providers. UnitedHealth's Optum arm employs or contracts roughly 90,000 physicians, on the order of one in 10 American doctors, and Optum is a large share of the company's revenue. CVS owns Aetna, a top-three pharmacy benefit manager, 9,000 pharmacies, and a chain of senior primary care clinics. Cigna owns Express Scripts. Humana and Elevance have built their own clinic and home-health arms. An insurer with 90,000 physicians can threaten disruption in a way a pure insurer never could, and every one of these companies has an incentive to buy more practices between now and the vote. The full map of who owns what is in Appendix G.

But the same fact is an opportunity. Those physicians, clinics, and home health agencies are care delivery capacity that already exists. Without intending to, UnitedHealth has built a physician network, clinic infrastructure, and home health operation large enough to be the starting base for a public delivery system.

What happens to each part of the industry

The insurance business is wound down. The company stops writing new policies, keeps enough in reserve to pay the claims it has already taken on, and a supervisor oversees that run-off until the last claim is settled and the entity closes. Insurers are not leveraged like banks; they hold reserves against claims already incurred, and run-off is an ordinary, well-established process with an industry built around it. Nobody has to be compensated for this. There is no property right in a market continuing to exist after Congress has changed it. Shareholders get their capital back through the wind-down. What they do not get is compensation for the profits the law has eliminated. The legal basis is in Appendix G.

The pharmacy benefit managers are abolished outright. Three of them, all affiliated with insurers, handle something like 80% of American prescriptions, and their business is the gap between the price they negotiate and the price they charge. One public price leaves them nothing to do. This is the one piece with bipartisan support already.

The care delivery assets are separated from the insurer and kept operating. Physician groups, clinics, surgery centers, home health, and pharmacies are divested from the insurance parent at fair market value struck at the lookback date, and thereafter operate under the ordinary ownership rules this plan sets for all providers. National networks like Optum become many regionally governed entities, not one national provider. The doctor keeps the same office and the same patients.

The ancillary businesses mostly evaporate. A large industry exists to process, review, contest, and deny claims because there are many payers with different rules and an incentive to pay less. A single public payer does not generate that work. The few pieces worth keeping, software that moves records between doctors and coordinates care across providers, continue as ordinary vendors bidding for contracts, with no stake in the care itself.

The companies remain. What goes away is the bureaucracy that used to define the private system: the risk scores, the prior authorizations, the denials, and the network fights.

Medicare Advantage

Medicare Advantage is Medicare run by a private insurer, paid a fixed amount per enrollee. Over 33 million people, about half of all Medicare beneficiaries, are in it, and Congress's own advisers estimate the plans are paid on the order of 20% more than the same people would cost in traditional Medicare. It is one of the hardest political fights in this plan, because the money buys real benefits that seniors enjoy, and any change will be sold to them as a loss. The answer is that dental, vision, hearing, prescription drugs, and care coordination become baseline benefits for everyone, and long-term care, which no Medicare Advantage plan covers at all, is included. Detail in Appendix G.

The Health Workers Transition Guarantee

• Eligibility stamped to the announcement date, covering anyone in insurance, PBM, or provider billing and revenue cycle work, including contractors and outsourced staff, and, named explicitly, licensed insurance brokers and agents, many of whom hold a small-business book and an in-person relationship with an employer in every congressional district.
• A retention premium for staying through the run-out. Billing departments are needed for an extended period of run-out claims after the payer changes, and a guarantee that pays from day one would empty them exactly when they are needed. The full benefit is conditioned on staying through a certified run-out completion date.
• Full wage replacement for three years, tapering over five, with no requirement to prove the layoff was caused by the Act. Causation tests were a major reason Trade Adjustment Assistance failed in practice (see Appendix G).
• Wage insurance: if you take a lower-paying job, the program pays a share of the difference for several years. The barrier is often not the training. It is the pay cut.
• Tuition-free retraining with a living stipend at any public institution, for any health field, and a legal right of first refusal on jobs in the new public system and the new capacity, for a defined window.
• Pension protection and an early retirement bridge from 55.
• Named regional packages for health care industry hubs like Hartford and Louisville, negotiated with the unions and the states before the phase-out date.
• The enforcement mechanism: wind-down payments and divestiture proceeds to shareholders are conditioned on the company honoring the guarantee. The money going out the door to owners is contingent on how the workers are treated.

Ownership: ban the dividend, not the owner

America's problem is not that its hospitals are privately owned. South Korea runs the most privately owned hospital system in the developed world, and almost none of it is investor-owned, because a Korean hospital may be private but may not pay out profits. Japan's hospitals are mostly small private institutions under similar restrictions on investor ownership. Both spend a fraction of what America spends and get more for it. Nor is America an outlier on for-profit ownership: at 17.4% investor-owned beds, it sits in the middle of the developed world, below Germany, France, and Spain. Whatever is wrong here, "too many for-profit hospitals" is not what separates America from the countries that work. What separates them is the conditions attached to the money. The comparative evidence is in Appendix H.

Providers may stay private. A hospital, a practice or a clinic may be investor-owned, non-profit, religious or public, and this plan converts none of them.

Billing the public payer comes with conditions. No distributing profits to shareholders. No refusing patients the public system covers. No setting your own prices. These are the terms on which the national payer buys care, and a provider unwilling to accept them does not have to, which is what keeps the arrangement voluntary in law. That is a narrower ask than nationalization and a harder one to argue against.

Keeping providers honest. To stop a provider raising its returns by lowering quality or selling off assets: no sale-leaseback or mortgaging of core clinical real estate without regulatory approval, no debt-funded payouts to owners, the national staffing ratios described in the workforce section, and open books, including full public reporting of related-party transactions.

Public ownership

Private providers continue, and the public system expands alongside them. Where a rural hospital has shut and no private operator will reopen it, the public builds and runs it. A publicly run system in every region sets a floor on quality and a reference point on cost, the way public universities do; the VA already plays this role, and plays it better than its reputation suggests.

Taking over an existing provider is the exception, reserved for operators who have stripped assets or endangered patients and so forfeited the presumption that they should be trusted with public money. The routes, in order of preference, are state charitable-trust and licensure authority, antitrust divestiture, fraud enforcement, and eminent domain in narrow cases. Each is explained in Appendix H.

The systems we already run

The federal government already directly runs or directly finances care for tens of millions of Americans: veterans, service members and their families, tribal nations by treaty, people in federal custody, and the citizens of five territories. It runs them at starkly different levels of generosity, from $13,473 per person nationally to $4,078 per person for the care it owes by treaty to Native Americans. This plan strengthens every one of them. The detail, including the statutes each fix amends, is in Appendix I.

• The VA is preserved, and every veteran becomes eligible. Enrollment stops being rationed by disability rating and priority group. VistA's successor becomes the national record, run by the clinicians who have used one national record longer than anyone in America.
• The Indian Health Service is funded as the treaty obligation it is. Its funding becomes mandatory rather than discretionary, with advance appropriations so it is never interrupted by a shutdown, and a funded path to per-capita parity. Contract support and referred care would be fully funded, urban Indian health organizations are funded as part of the system, and nothing in the Act touches a treaty, the trust responsibility, or tribal self-governance. Tribes choose: run their own system, use the national system, or both.
• The territories get the whole plan. The capped Medicaid budgets and the below-formula match rate for Puerto Rico, Guam, the Virgin Islands, American Samoa, and the Northern Marianas are repealed, and every provision applies identically to their 3.5 million citizens.
• Incarcerated people are covered. The 1965 rule barring Medicaid payment for anyone in custody is repealed. Jails and prisons buy care from the community system at community prices, overseen by an independent inspectorate, and nobody falls off at either gate: enrollment continues after release, and people leave with their medications in hand and an appointment already booked.

Cancel medical debt, and pay back the people who paid

About 41% of American adults carry medical or dental debt, roughly 106 million people. Medical debt trades on the secondary market at pennies on the dollar, so canceling all of it is cheap, hundreds of millions to low billions of dollars for a face value in the hundreds of billions. It is among the least expensive measures in the plan, and it can be done on day one, before the rest is even built.

The people who paid are not left out. Medical debt payments made in the seven years before enactment are refunded, dollar for dollar, capped at $10,000 per person. Seven years is the window in which payment records reliably exist, and it reaches the people whose grievance is live: those still paying, and those who just finished. Wherever the records exist, in active payment plans, collection accounts and provider receivables, the refund is paid automatically with no form at all. The costing is in Appendix J.

What it costs and who pays

At maturity the plan saves $740 billion to $1.2 trillion a year, mostly from eliminating billing and administration, moving hospital and physician prices to a single schedule, and buying drugs at a public price. It spends $870 billion to $1.4 trillion a year on new things: operating the new capacity, the long-term care benefit, the extra care people use once cost-sharing goes to zero, covering the uninsured, dental, vision, and hearing, the capital program, the workforce pipeline, and the transition guarantee. The net runs from $680 billion a year worse to $340 billion better, centered near spending-neutral. The country pays roughly what it pays today and gets universal coverage, long-term care, dental and mental health, and the buildout for it.

The savings are deliberately conservative. Two lines carry most of the uncertainty. The largest is the operating cost of the new capacity: a construction program builds a great deal, and staffing and running what it builds costs more than building it, every year, for years to come. The second is induced use. Moving roughly 165 million already-insured Americans from real deductibles to zero could be a larger demand shock than covering the uninsured, and if the diagnosis in this plan is right, unmet need is large and free care will surface it. That is the plan working, and the budget has to cover it.

Some costs land once rather than every year. The medical debt refund is the largest, at $100–250 billion. And one liability has no number against it yet: when Congress changes the law in a way that breaches the government's own contracts, the Treasury pays damages, and this plan abrogates Medicare Advantage contracts covering 33 million people, among others. The full table line by line, what each number assumes, the one-off costs, and how the contract exposure is limited, are in Appendix J.

The transition: what changes, and when

The rule that governs the entire transition

Nobody loses anything before they gain something. Relief arrives on top of the plan you have, years before the plan you have goes away.

Every plan like this one has died on the same sentence: you will lose the plan you have. The sentence works because it is true, and because the loss it names is concrete and immediate while the replacement is abstract and years away.

This plan takes that sentence away by changing the order. Nothing anyone holds is replaced until the relief has already arrived and been running for years. By the time the public payer takes over a family's coverage, the concrete and present thing is the gain: the debt that was canceled, the drugs that cost nothing at the counter, the out-of-pocket bills that stopped at a thousand dollars, and the payment that has been going to the relative doing the caring.

The demand arrives before the buildings

Making care free in year one is likely to increase demand quickly. The buildings do not arrive until year six and the full workforce not until year 10, so something has to close the gap. The size of the surge is known from the one randomized experiment ever run on it, and the cost section budgets for it. Money is not the constraint. Clinicians and exam rooms are.

The best moves here do not suppress demand. They delete appointments that exist only as friction, and every one of them is already in the technology section as a consumer convenience: the prescription that renews itself, so the visit that existed only to renew it disappears; the standing referral, so a permanent condition is never reauthorized; asynchronous primary care for the large share of visits that may not need a scheduled slot; and, past the waiting-time guarantee, an automatic search for a slot elsewhere that books it and pays your travel, which turns a wait of 11 weeks at the nearest hospital into nine days an hour away. The evidence is in Appendix K.

What cannot be fast

• An appointment sooner. Year six at the earliest, and year 10 before the gap closes. The fast levers (telehealth, retired-clinician re-entry, pharmacist prescribing, full practice authority) partially fill the gap, but training produces no new doctor before year seven.
• A dentist. Dental supply is thinner than physician supply and there is no equivalent of the mandatory residency lever. Hence children and seniors first, the only phase-in the supply permits.
• A rural hospital. Reopenings and renovations can happen in years two to three. New construction is four to seven years.
• Long-term care as a full benefit. Japan built its care-manager workforce and national assessment instrument before the benefit went live, and we copy that exactly: an assessor corps in years one to three, and the benefit in years four to five. Meanwhile the existing waiting lists are cleared, and the caregiver allowance is paid from the day of application, because it has no workforce constraint.
• Mental health. Capacity is the binding constraint.

A plan that promises money in 12 months and care in six years, and then delivers the money in 12 months, is judged a success in both.

The cutover

Every transition of this kind fails, if it fails, at the cutover, and every one of the following is a rounding error in cost that becomes the story of the launch if it is missed. There is no eligibility determination: everyone physically present is covered, with no form, no verification, and no renewal, and the provider creates coverage by treating you. The public payer pays every claim within 180 days either side of a cohort's cutover regardless of what plan the patient held, and recovers from the prior plan afterward, so no patient is ever caught between two systems. Nobody mid-treatment changes payer or authorization; every prior authorization in force on cutover day is honored for 12 months. Every prescription presented at a pharmacy in the first 180 days is filled and paid, no questions asked. And nothing is switched off until its replacement has run in parallel for a year. The transitions each rule is written against, the 2006 Part D launch, the 2023 Medicaid unwinding, Canada's Phoenix payroll system, are in Appendix K.

The money gets worse before it gets better

Delivering relief first costs money before it saves any. It moves roughly $250 to $400 billion a year into years one through three, when the buildout, the training, the transition guarantee and the new benefits are all running and no savings line has begun to ramp. So the revenue clock runs with the relief clock, not the enrollment clock: the employer and household contributions begin in year one, when relief begins. And insurers have to cut premiums by the value of the liability the government takes off their books, which offsets a large share of the cost in the same year. That arrives as lower premiums rather than revenue, so it does nothing for the federal deficit, but it cuts what each household pays, which is the number that decides whether a family is better off.

The sequence

When	What happens
Campaign, 2028	The household calculator publishes, so every claim in this plan becomes a number a family can look up about itself.
Enactment	Medical debt is canceled and collection stops. A prior-authorization request unanswered inside the deadline is approved automatically, care is provided at the insurer's expense while an appeal runs, a permanent condition is authorized permanently, and balance billing ends. No plan may price above the prior year, and each year it must fall by the value of what the government has taken off the insurer's books. None of this needs a rule, a payment rail, or an appropriation.
Year 1	Training starts, because it pays off in year eight: residencies, tuition, nursing faculty. The drug prize fund opens. Chronic-disease drugs go to zero at the pharmacy counter through the federal supply chain that already serves the VA. The caregiver allowance begins paying the family member already doing the care. Primary care goes to zero, out-of-pocket costs are capped at $1,000 a person, and glasses and hearing aids are covered. The national appointment search goes live. The rate-setting corps, the public survey of procedure times, and the county-by-county capacity survey all stand up.
Months 3 to 9	The supply that needs no building. Telehealth at payment parity with licensure preemption, full practice authority and pharmacist prescribing, retired-clinician re-entry, and the federal relief corps covering clinics that cannot fill a shift.
Years 1 to 2	Payer construction begins. Ownership conditions take effect in cooperating states first. The Health Workers Transition Guarantee starts paying before any job ends.
Years 2 to 4	Staffing before buildings, which is the order most plans get backwards. Capital in this window goes to reopening and renovating, because that is all that can physically be delivered.
Years 3 to 6	Enrollment by cohort on the calendar: children and pregnancy, then everyone 55 and over, then everyone. Construction waits on the capacity survey. Coverage does not, because what enrollment delivers is financial.
Years 4 to 10	New hospitals and clinics open. Prices converge through multi-year corridors, not by decree. The long-term care benefit is live from year four. The first physicians trained under the program arrive in year eight. Steady state around year ten.

It takes 10 years, and the first check clears in 12 months. A plan promising transformation in 18 months is not believable and will be judged a failure in month 19.

What modern technology makes possible, and nobody has asked for

In American health care, the delay, the paperwork, and the opacity do not slow the system down. They are how the system makes money.

Every one of them moves money or risk from a company to a patient. A prior-authorization request that takes 11 days is a process working exactly as designed, because a real share of delayed requests are abandoned by patients who give up waiting, and the insurer never pays the claim. A bill that arrives four months later, from a company you have never heard of, is a collection strategy. Nobody built any of this badly. They built it for a purpose that is not yours. The fix is to make the friction expensive.

The National Prior Authorization Service. One federal portal through which every prior-authorization request in the United States must flow, for every plan in America including employer plans. Your doctor's office submits into it, your insurer answers into it, and you can watch it happen on your phone. The clock is the one Medicare Advantage already follows, 72 hours expedited and 7 days standard, and a request unanswered inside it is approved by operation of law. Every denial carries the name of a licensed, same-specialty clinician who personally reviewed it. Appeals go to an independent reviewer, not the insurer, and where a treating physician certifies that even 72 hours carries a risk of harm, the care is provided at the insurer's expense while the appeal runs. An insurer whose denials are overturned above a published threshold loses the right to use prior authorization for that service line for two years. The equilibrium is that the cheapest strategy becomes approving nearly everything, and prior authorization ends because the insurers switch it off themselves, in public, on a dataset we publish. The full design, the constitutional reason the penalties are statistical rather than adjudicated, and the ways it goes wrong, are in Appendix L.

The instant appointment. Every provider billing any payer must publish real-time appointment availability in a machine-readable feed, and one national search reads them all: orthopedist, 30 miles, this week. It arrives in the first year because it needs no payer, no enrollment, and no money. It makes the queue visible, which is the measurement this kind of plan most needs and least often has, and it creates competition on speed in a system where the fee schedule fixes every price.

Price preclusion. No provider may bill a patient any amount that was not published on the national price API before the service. You may charge only what you published, so no patient can be surprise-billed and no arbitration is needed.

The auto-filling prescription. Chronic maintenance drugs auto-refill and ship at $0, with no renewal call and no annual reauthorization, until a clinician stops them. A large share of primary care appointments exist only to renew a prescription, and deleting the renewal deletes the visit without denying anyone anything.

The standing referral. Diagnosed with a permanent condition, and all care and medication for it is pre-authorized permanently. It is one sentence of statute with no infrastructure behind it, and it ends the January scramble about a drug you have taken all year.

Real-time claims. For most encounters the claim is fixed once the codes are entered. Pay at the point of service, like a card transaction, and audit a sample afterward, the way tax administration already works.

The reverse-auction on the wait. Once the guarantee clock runs out, the system searches for a slot elsewhere, books it, and covers your travel. You do nothing.

There is a second reason to build all of this early. Once every prior-authorization request, every appointment feed, every published price, and every first-dollar drug payment runs through federal infrastructure, the government owns the eligibility engine, the provider directory, the fee schedule's publication layer, the claims pipeline and the enrollment roster of a single payer, years before the payer exists, under names nobody can oppose. One objection to Medicare for All is that CMS cannot stand up a $3.6 trillion payer in one big-bang switch-on. In this plan every part has been running at national scale for three years, debugged in public, with the private insurers as the test population.

How this passes

Under the Senate's current rules this one could not either. Its money could pass by a simple majority through budget reconciliation. Its rules could not: the conditions on providers, the staffing ratios, the abolition of the pharmacy benefit managers, all of it would be struck under the Byrd rule, which removes from a reconciliation bill anything whose budgetary effect is merely incidental to a policy change. The Parliamentarian has applied that rule to a $124 billion immigration provision and a $15 minimum wage alike. The Affordable Care Act got its rules through only because Democrats held 60 seats for a few months in 2009, and no party will hold 60 seats again in any Senate anyone can foresee.

So this plan assumes the filibuster is gone, and says so. That is not a detail of procedure. It is the precondition. A majority that wants this plan has to be willing to end the filibuster to pass it, and a majority unwilling to do that should not pretend it can pass the plan another way. The bill is then one bill, the money and the rules in the same statute, passed by 51 votes. Appendix M sets out exactly what reconciliation could and could not carry, which is the case for why the filibuster has to go.