By NextBestFitCoverage tied to residence, not job or income
Under single payer or a regulated multi-payer system, coverage never depends on employment or income, so life changes do not end coverage.
Follows from residence-based coverage.
Review ledgerHow this path connects
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Base eligibility only on residence
- Remove income and employment checks from enrollment
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
- People lose coverage when their life changes (churn)
Residence-based coverage removes re-enrollment, gaps between jobs, and Medicaid income redetermination paperwork for states and families. Life changes no longer end coverage or interrupt continuity with the same doctors.
- About $1 trillion a year in administrative cost
Residence-based coverage removes Medicaid redetermination paperwork for states and families.
- Depends on other changes to work
Residence-based coverage requires a larger change to the payer structure.
- Adds paperwork, coordination, or complexity
Verifying residence still creates paperwork.
Who's affected
- People whose job, income, or home changes
- People lose coverage when their life changes (churn): They lose coverage when income, job, or address changes.
- People with ongoing or specialist care needs
- People lose coverage when their life changes (churn): Treatment is interrupted when coverage lapses mid-course.
- State governments
- People lose coverage when their life changes (churn): Residence-based coverage removes re-enrollment, gaps between jobs, and Medicaid income redetermination paperwork for states and families. Life changes no longer end coverage or interrupt continuity with the same doctors.
- Doctors, nurses, and other clinicians
- About $1 trillion a year in administrative cost: Time goes to billing and insurer rules instead of patients.
- People with employer coverage
- About $1 trillion a year in administrative cost: Premiums pay for the administration.
- Taxpayers and public budgets
- About $1 trillion a year in administrative cost: Public programs pay for it too.
- Health insurers, brokers, and their shareholders
- People lose coverage when their life changes (churn): Insurers avoid the long-term costs of members who leave.
- About $1 trillion a year in administrative cost: Insurers, billing firms, and clearinghouses earn from the complexity.
- Taxpayers and public budgets
- People lose coverage when their life changes (churn): Budgets save money when eligible people fall off.
- Insurance and billing workers
- About $1 trillion a year in administrative cost: Their jobs exist because of the complexity.
- Health administration and software vendors
- Depends on other changes to work: Residence-based coverage requires a larger change to the payer structure.
- Retrain eligibility caseworkers for residence verification and navigation
Where it has been tried
- Most OECD countries: Coverage is based on residence or legal status.
- Canada: In 2023–2024, Canada's provinces and territories reciprocally billed about C$1 billion for insured hospital and physician care outside patients' home jurisdictions.Sources: Health Canada (2025)