By NextBestFitDrop point-of-care charges entirely
Remove the problem at its source: no copays for covered services.
No charges for core covered care.
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This path
Drop point-of-care charges entirely
Requires:
No cost sharing at the point of careUnderinsurance: covered, but can't afford to use itChosenCreates or worsens
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Remove all point-of-care charges
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
What it fixes
- Copays keep billing systems alive and still deter poorer patients
Eliminating copays for covered services removes the copay billing apparatus and avoids deterring needed care.
- About $1 trillion a year in administrative cost
Eliminating copays for covered services removes the billing apparatus for those charges.
What it creates or worsens
- Longer waits if demand grows faster than capacity
Removing copays increases use of care, adding demand to the system.
12 paths soften this
Legal wait-time guaranteesLonger waits if demand grows faster than capacityChosenBuild capacity before demand risesLonger waits if demand grows faster than capacityChosenPay for activity on top of budgetsLonger waits if demand grows faster than capacityChosenFund more residency slotsPhysician shortage, especially in primary careChosenFull practice authority for NPs, PAs, pharmacists, dental therapistsScope-of-practice limits waste capacityChosenTeam-based care with physician oversightScope-of-practice limits waste capacityRejectedFee-for-service at public fee scheduleU.S. prices are far higher than in other countriesChosenKeep means testing, but expand home careLong-term care requires spending down to povertyChosenAllow private insurance for covered servicesTwo-tier care: a private fast lane for those who can payRejectedBudgets adjust automatically for population, age, and volumeFixed budgets can ration careChosenBase budget plus activity paymentsFixed budgets can ration careChosenWaiting-time guarantees as a backstopFixed budgets can ration careChosen - Raises spending or loosens control over it
Eliminating charges for covered services increases use of care.
- Replacing premiums with taxes
Eliminating copays requires higher taxes.
Who's affected
Who gains
- Low- and middle-income households
- Copays keep billing systems alive and still deter poorer patients: Point-of-care charges deter care, especially for poorer patients.
- Replacing premiums with taxes: Income-based taxes replace flat premiums that took a large share of their pay.
- People with ongoing or specialist care needs
- Copays keep billing systems alive and still deter poorer patients: Point-of-care charges deter care, especially for poorer patients.
- Hospitals, clinics, and care organizations
- Copays keep billing systems alive and still deter poorer patients: Copays require collection, exemptions, and billing work.
- 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.
Who loses
- Health administration and software vendors
- Copays keep billing systems alive and still deter poorer patients: Copays preserve demand for billing services.
- Health insurers, brokers, and their shareholders
- About $1 trillion a year in administrative cost: Insurers, billing firms, and clearinghouses earn from the complexity.
- Insurance and billing workers
- About $1 trillion a year in administrative cost: Their jobs exist because of the complexity.
- People with employer coverage
- Longer waits if demand grows faster than capacity: They are seen fastest today and would share one queue with everyone.
- People with ongoing or specialist care needs
- Longer waits if demand grows faster than capacity: They need specialists and procedures most often.
- Taxpayers and public budgets
- Raises spending or loosens control over it: Public budgets pay the added spending.
- High earners
- Replacing premiums with taxes: They pay more under income-based taxes than they did in flat premiums.
- Employers
- Replacing premiums with taxes: Businesses that never offered coverage start paying toward it.
Where it has been tried
- UK, Canada: No charges for covered hospital and physician care.
- Canada: Under the Canada Health Act, provinces must prohibit point-of-care patient charges for medically necessary care or face dollar-for-dollar federal transfer deductions, under which $62.2 million was levied in March 2025.Sources: Health Canada (2025)