By NextBestFitSingle public payer for everyone
One public program covers every resident automatically. Private insurance for covered services ends; providers stay mostly private and bill one payer at one set of rates.
Only path that ends churn, networks, job lock, and most admin cost at once; matches the site's cost model.
To review: The biggest call on the site. Weigh against regulated multi-payer (Germany/Switzerland), which keeps plan choice with smaller savings.
Review ledgerHow this path connects
This path
Single public payer for everyone
Creates or worsens
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Create a national health program (or expand Medicare) covering every resident, with automatic enrollment from tax, Social Security, and immigration records
- Prohibit private insurance from selling coverage that duplicates the public benefit
- Fold Medicare, Medicaid, CHIP, ACA marketplace subsidies, FEHB, and TRICARE civilian coverage into the program; decide whether the VA and IHS stay separate
- Replace employer premiums, employee premiums, and state Medicaid spending with dedicated taxes and maintenance-of-effort payments
- Build one national enrollment, eligibility, and claims-payment system with a member card
- Set one national fee schedule and/or hospital budgets, with regional adjustments
- Amend ERISA so employer self-insured health plans end for covered services
- Fund a worker transition program for insurer, broker, and billing staff
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
- Tens of millions of people have no coverage
Every resident is enrolled automatically from tax, Social Security, and immigration records, with nothing to sign up for or lose. Taiwan's single payer covers over 99% of residents.
- People lose coverage when their life changes (churn)
Coverage no longer ends when income, job, family, or state changes.
- Job lock: people stay in jobs to keep insurance
Coverage no longer depends on having or keeping a job.
- Narrow networks and out-of-network surprises
Every provider bills the same payer, so there are no networks to be in or out of.
- Premiums are a large, flat, hidden tax on wages
Premiums end. The money moves into taxes instead (see Replacing premiums with taxes).
- Surprise billing and a runaway arbitration system
With one payer and one fee schedule, no provider is out of network, so there is no surprise bill.
- Insurer overhead and profit
Private insurers stop administering covered care, so their overhead and profit on it end. Taiwan's administrative cost is about 1% of spending.
- About $1 trillion a year in administrative cost
Providers deal with one claims system and one set of rules instead of hundreds.
- Claim denials
One public rulebook replaces each insurer's prior-authorization and denial rules. Denials still happen, but under one appeal system.
- U.S. prices are far higher than in other countries
One buyer sets rates for all care. Employer plans paid hospitals 2.54× what Medicare paid in 2022, and that gap is what one rate schedule closes.
Sources: RAND Corporation (2024)
What it creates or worsens
- Transition disruption: jobs, companies, and familiar coverage
About 178.6 million people leave employer plans, and insurers lose their core business.
Sources: CMS Office of the Actuary (2025)7 paths soften this
Phased transition in wavesTransition disruption: jobs, companies, and familiar coverageChosenFast transition in one or two yearsTransition disruption: jobs, companies, and familiar coverageRejectedState pilots firstTransition disruption: jobs, companies, and familiar coverageRejectedRegulated multi-payer: everyone must have a non-profit or tightly regulated planTens of millions of people have no coverageRejectedPublic option alongside private insuranceTens of millions of people have no coverageRejectedLower the Medicare age step by step (and enroll children at birth)Tens of millions of people have no coverageRejectedPrivate supplemental plans for extrasLosing the choice of health plan and insurer competitionChosen - Simplifying billing would displace hundreds of thousands of workers
Most insurer, broker, and billing work for covered care ends; 451,820 people work at health insurance carriers alone.
Sources: Bureau of Labor Statistics (2026) - Longer waits if demand grows faster than capacity
Care with no premiums or networks gets used more. Unless capacity grows too, waits get longer, and people seen fastest today notice most.
Sources: RAND Corporation (1986)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 - Losing the choice of health plan and insurer competition
There is no other insurer to switch to if the public plan is run poorly.
8 paths soften this
Hold the single payer to service standardsLosing the choice of health plan and insurer competitionChosenPrivate supplemental plans for extrasLosing the choice of health plan and insurer competitionChosenLet people choose among public care organizationsLosing the choice of health plan and insurer competitionChosenRegulated multi-payer: everyone must have a non-profit or tightly regulated planTens of millions of people have no coverageRejectedIncome-based premiums in a multi-payer systemPremiums are a large, flat, hidden tax on wagesRejectedFix Medicare Advantage paymentsMedicare Advantage overpayments and coding intensityChosenTighter medical-loss ratios and non-profit requirementInsurer overhead and profitRejectedStandardize across many payersAbout $1 trillion a year in administrative costChosen - Replacing premiums with taxes
Taxes replace premiums and most out-of-pocket costs. In CBO's single-payer options, federal subsidies rise by $1.5 trillion to $3 trillion in 2030.
Sources: Congressional Budget Office (2020) - Central coverage decisions can feel like rationing
One public body decides what is covered for everyone, so each 'no' applies nationwide.
3 paths soften this
Independent, transparent coverage body with appealsCentral coverage decisions can feel like rationingChosenCover everything clinically effective, without cost thresholdsCentral coverage decisions can feel like rationingRejectedClinician-led exceptions with fast reviewCentral coverage decisions can feel like rationingChosen - States lose control and budgets shift between levels of government
A national program replaces state-run Medicaid and CHIP, along with the state choices built into them.
Who's affected
Who gains
- Uninsured people
- Tens of millions of people have no coverage: They delay care, go without, or pay full price.
- People whose job, income, or home changes
- People lose coverage when their life changes (churn): They lose coverage when income, job, or address changes.
- Job lock: people stay in jobs to keep insurance: Would-be founders, early retirees, and caregivers stay in jobs to keep insurance.
- People with ongoing or specialist care needs
- People lose coverage when their life changes (churn): Treatment is interrupted when coverage lapses mid-course.
- Narrow networks and out-of-network surprises: Needed specialists and therapists are often out of network.
- Surprise billing and a runaway arbitration system: Ambulance rides and out-of-network specialists send bills patients didn't choose.
- Claim denials: Care is delayed or denied, and appeals take time.
- Low- and middle-income households
- Premiums are a large, flat, hidden tax on wages: A flat premium takes a large share of a modest paycheck.
- Replacing premiums with taxes: Income-based taxes replace flat premiums that took a large share of their pay.
- Employers
- Premiums are a large, flat, hidden tax on wages: Small employers pay the same premiums on lower payrolls.
- People with employer coverage
- Surprise billing and a runaway arbitration system: Premiums fund the higher arbitration awards.
- Insurer overhead and profit: Premiums pay for insurer overhead and profit.
- About $1 trillion a year in administrative cost: Premiums pay for the administration.
- U.S. prices are far higher than in other countries: Private plans pay the highest prices, passed on through premiums.
- Doctors, nurses, and other clinicians
- About $1 trillion a year in administrative cost: Time goes to billing and insurer rules instead of patients.
- Claim denials: Providers absorb unpaid claims and appeal work.
- Taxpayers and public budgets
- About $1 trillion a year in administrative cost: Public programs pay for it too.
- U.S. prices are far higher than in other countries: Public programs pay more than peer countries too.
- Central coverage decisions can feel like rationing: Declining low-value care holds down public spending.
Who loses
- Employers
- Tens of millions of people have no coverage: Employers that don't offer coverage avoid its cost.
- Job lock: people stay in jobs to keep insurance: Benefits help employers keep workers who would otherwise leave.
- Replacing premiums with taxes: Businesses that never offered coverage start paying toward it.
- Taxpayers and public budgets
- Tens of millions of people have no coverage: Public budgets avoid subsidy costs in the short run.
- People lose coverage when their life changes (churn): Budgets save money when eligible people fall off.
- Health insurers, brokers, and their shareholders
- People lose coverage when their life changes (churn): Insurers avoid the long-term costs of members who leave.
- Job lock: people stay in jobs to keep insurance: Insurers and brokers sell group coverage through employers.
- Narrow networks and out-of-network surprises: Narrow networks let insurers offer lower premiums.
- Premiums are a large, flat, hidden tax on wages: Premiums are insurers' revenue.
- Insurer overhead and profit: Overhead and profit are insurers' income.
- About $1 trillion a year in administrative cost: Insurers, billing firms, and clearinghouses earn from the complexity.
- Claim denials: Denials lower insurers' medical spending.
- Transition disruption: jobs, companies, and familiar coverage: Insurers lose their core business, and shareholders lose value.
- Hospitals and specialist groups with high private prices
- Narrow networks and out-of-network surprises: Out-of-network providers can bill high charges.
- Surprise billing and a runaway arbitration system: Private-equity-backed emergency, anesthesia, and radiology groups win high awards.
- U.S. prices are far higher than in other countries: Providers with pricing power earn more per service.
- High earners
- Premiums are a large, flat, hidden tax on wages: A flat premium is a small share of high pay.
- Replacing premiums with taxes: They pay more under income-based taxes than they did in flat premiums.
- Insurance and billing workers
- About $1 trillion a year in administrative cost: Their jobs exist because of the complexity.
- Transition disruption: jobs, companies, and familiar coverage: Jobs selling coverage and processing claims end.
- Simplifying billing would displace hundreds of thousands of workers: Workers lose jobs if billing is simplified without a transition plan.
- Drug and device makers
- U.S. prices are far higher than in other countries: U.S. prices are well above those in peer countries.
- Central coverage decisions can feel like rationing: A declined product loses the whole national market.
- People with employer coverage
- Transition disruption: jobs, companies, and familiar coverage: People leave plans most of them rate well, and must re-learn how coverage works.
- Longer waits if demand grows faster than capacity: They are seen fastest today and would share one queue with everyone.
- Losing the choice of health plan and insurer competition: They can't keep or pick a plan they like, or switch if service is poor.
- People with ongoing or specialist care needs
- Longer waits if demand grows faster than capacity: They need specialists and procedures most often.
- Central coverage decisions can feel like rationing: People needing a declined or delayed treatment have no other insurer to turn to.
- State governments
- States lose control and budgets shift between levels of government: States that designed their own programs lose control, and budgets shift between levels of government.
Where it has been tried
- Taiwan: National Health Insurance (1995) covers 99%+ of residents with one payer and a smart card; administrative cost is about 1% of spending (1.07% in 2014, per Brookings).
- Canada: Provincial single payers for hospital and physician care; drugs, dental, and vision are largely outside the public plan.
Costs this path changes
Conflicts with (choose one or the other)
Regulated multi-payer: everyone must have a non-profit or tightly regulated planTens of millions of people have no coverageRejectedPublic option alongside private insuranceTens of millions of people have no coverageRejectedIndividual mandate with larger subsidiesTens of millions of people have no coverageRejected
Works well with
All-payer rate settingU.S. prices are far higher than in other countriesChosenGlobal budgets for hospitalsU.S. prices are far higher than in other countriesChosenLower the Medicare age step by step (and enroll children at birth)Tens of millions of people have no coverageRejectedCover the territories in the national program on the same terms as the statesU.S. territories get capped, lower federal health fundingChosen
Other paths that depend on this one
Coverage tied to residence, not job or incomePeople lose coverage when their life changes (churn)ChosenDecouple coverage from employmentJob lock: people stay in jobs to keep insuranceChosenReplace premiums with progressive taxesPremiums are a large, flat, hidden tax on wagesChosenPublic coverage rules with clinician-led reviewClaim denialsChosenFold Medicare Advantage into the public programMedicare Advantage overpayments and coding intensityChosenPublic administration with a cost targetInsurer overhead and profitChosenCut documentation and billing burdenClinician burnout from paperwork and EHR workChosenOne claims system and standard rulesAbout $1 trillion a year in administrative costChosen
Other paths for “Tens of millions of people have no coverage”
Regulated multi-payer: everyone must have a non-profit or tightly regulated planTens of millions of people have no coverageRejectedPublic option alongside private insuranceTens of millions of people have no coverageRejectedLower the Medicare age step by step (and enroll children at birth)Tens of millions of people have no coverageRejectedAutomatic enrollment with free default coverageTens of millions of people have no coverageChosenIndividual mandate with larger subsidiesTens of millions of people have no coverageRejected