By NextBestFitPhased transition in waves
Move groups in stages (e.g., uninsured and children first, then Medicaid, then the individual market, then employer plans) over four or more years.
Waves over several years; matches the site's draft plan.
Review ledgerHow this path connects
This path
Phased transition in waves
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Move groups in waves over 4+ years
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
- Transition disruption: jobs, companies, and familiar coverage
Moving coverage groups in stages lets systems be tested before the full load arrives and gives workers time to transition.
What it creates or worsens
- About $1 trillion a year in administrative cost
Moving groups in stages requires the old and new systems to operate in parallel.
21 paths soften this
One claims system and standard rulesAbout $1 trillion a year in administrative costChosenStandardize across many payersAbout $1 trillion a year in administrative costChosenSingle public payer for everyoneTens of millions of people have no coverageChosenRegulated 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 coverageRejectedContinuous eligibility (12-month or multi-year) in Medicaid and CHIPPeople lose coverage when their life changes (churn)ChosenCoverage tied to residence, not job or incomePeople lose coverage when their life changes (churn)ChosenNo cost sharing at the point of careUnderinsurance: covered, but can't afford to use itChosenEvery licensed provider is in-networkNarrow networks and out-of-network surprisesChosenPrevent new debt by ending point-of-care billsMedical debt affects about 100 million peopleChosenEliminate out-of-network statusSurprise billing and a runaway arbitration systemChosenEliminate prior authorization except for a short listPrior authorization delays and blocks careChosenPublic administration with a cost targetInsurer overhead and profitChosenPublic review of hospital budgetsExecutive pay and nonprofit statusChosenCut documentation and billing burdenClinician burnout from paperwork and EHR workChosenGlobal budgets for hospitalsU.S. prices are far higher than in other countriesChosenLower costs for clinicians, not only payProviders leave, retire, or go cash-only if pay dropsChosenFast transition in one or two yearsTransition disruption: jobs, companies, and familiar coverageRejectedAutomatic exemptions and annual collection through taxesCopays keep billing systems alive and still deter poorer patientsChosenDrop point-of-care charges entirelyCopays keep billing systems alive and still deter poorer patientsChosenReport measures publicly without tying pay to themTargets and quality metrics invite gamingRejected - Takes years, or money up front, before it pays off
Moving groups in stages extends the time before the new system delivers its full savings.
Who's affected
Who gains
- 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.
- Insurance and billing workers
- Transition disruption: jobs, companies, and familiar coverage: Jobs selling coverage and processing claims end.
- About $1 trillion a year in administrative cost: Their jobs exist because of the complexity.
- Health insurers, brokers, and their shareholders
- Transition disruption: jobs, companies, and familiar coverage: Insurers lose their core business, and shareholders lose value.
- About $1 trillion a year in administrative cost: Insurers, billing firms, and clearinghouses earn from the complexity.
- People whose job, income, or home changes
- Transition disruption: jobs, companies, and familiar coverage: Moving coverage groups in stages lets systems be tested before the full load arrives and gives workers time to transition.
Who loses
- 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.
Where it has been tried
- Canada: Canada expanded universal coverage in stages: the federal Hospital Insurance and Diagnostic Services Act passed in 1957, all provinces and territories had universal hospital insurance by 1961, the Medical Care Act passed in 1966, and all provincial and territorial plans included physician services by 1972.Sources: Health Canada (2025)