By NextBestFitAutomatic enrollment with free default coverage
Keep today's mix of coverage, but automatically enroll anyone without coverage into a zero-premium plan (Medicaid or a free marketplace plan) using tax and benefit data.
Interim: enroll uninsured people in free coverage while the public program is built.
To review: Only a bridge; check it doesn't delay the main transition.
Review ledgerHow this path connects
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Allow IRS, SSA, and state agencies to share data to identify uninsured residents
- Enroll uninsured people automatically in Medicaid or a zero-premium marketplace plan
- Fully fund zero-premium plans for everyone below a set income
- Allow retroactive coverage for anyone who arrives at a hospital uninsured
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
- Tens of millions of people have no coverage
Using tax and benefit data to enroll uninsured people in free existing plans closes most coverage gaps with little disruption and at the lowest cost among the described routes to near-universal coverage. Data matching can still miss people.
- Solves only part of the problem
Free-premium default plans may still have high cost sharing. Automatic enrollment preserves the existing system's costs, complexity, networks, and denials.
Who's affected
- Uninsured people
- Tens of millions of people have no coverage: They delay care, go without, or pay full price.
- Employers
- Tens of millions of people have no coverage: Employers that don't offer coverage avoid its cost.
- Taxpayers and public budgets
- Tens of millions of people have no coverage: Public budgets avoid subsidy costs in the short run.
Where it has been tried
- Massachusetts: 2006 reform with subsidies and a mandate reached about 97% coverage.
- Netherlands: In 2023, about 28,500 people remained uninsured in the Netherlands, which identifies uninsured residents and can collect insurance premiums from wages.Sources: Commonwealth Fund (2026)