Universal HealthcareBy NextBestFit
Phase 1 · Year 0: the 18 months between signing and first coverage

Enactment & build

Stand up the agency, the money, the systems, the rules, and the people, so that coverage day works.

Done when
  • Claims system processes 100% of Medicare volume in parallel testing with error rates at or below current Medicare contractors.
  • Every Year-1-eligible person has an identifier and a card mailed.
  • At least 90% of physicians who bill Medicare today have signed UHP participation agreements.
  • Every hospital has a Year-1 global budget.
  • The national formulary covers 100% of drugs currently on Medicare Part D formularies.
  • IRS withholding tables published for the new taxes.

Changes from chosen paths in this phase: 98

54 chosen solution paths (draft picks awaiting review) land in this phase. See every change.

Detailed steps

  1. 1.1
    Create the Universal Health Administration

    Stand up the agency that runs UHP by absorbing CMS's Medicare operations, then building out 10 regional offices, independent rate-setting and technology-assessment boards, and an Office of Patient Advocacy.

    7 tasks · 3 cost items · Months 0–18
  2. 1.2
    Create the UHP Trust Fund

    All dedicated revenues (the payroll taxes, household premium, state MOE, and redirected federal appropriations) flow into a single trust fund with permanent budget authority to pay claims, so a government shutdown never stops payment for care.

    4 tasks · 16 cost items · Months 0–12
  3. 1.3
    Build the claims, payment & data systems

    Scale Medicare's existing fee-for-service claims infrastructure from about 1.3 billion to about 5 billion claims a year, add hospital global-budget payments, dental and vision claim types, and a national real-time eligibility check.

    8 tasks · 1 cost items · Months 0–18, then continuous
  4. 1.4
    Enroll everyone automatically

    Nobody applies. Everyone with a Social Security number or ITIN and a U.S. address is enrolled from existing federal records; others enroll at any provider, Social Security office, or community health center with proof of residence.

    7 tasks · 1 cost items · Months 6–18 for Wave 1, then before each wave
  5. 1.5
    Define the benefit package & cost sharing

    Write down exactly what UHP covers, what it excludes, and what patients pay at the point of care: nothing for covered services. Out-of-pocket spending falls from $556.6B to $197.3B; what remains is for excluded items.

    7 tasks · 2 cost items · Months 0–12
  6. 1.6
    Sign up providers & set participation rules

    Every licensed provider that wants to bill UHP signs one participation agreement. Participating providers accept UHP payment as payment in full (no balance billing). Opted-out providers may see patients privately but cannot bill UHP for anyone.

    6 tasks · 0 cost items · Months 6–18
  7. 1.7
    Set the national fee schedule

    Adopt Medicare's RBRVS fee schedule as the base, raise primary care to 125% of Medicare, procedural specialties to 105%, and others to 112% on average. Physician & clinical UHP spending becomes $1.05T (price effect −$21.4B, utilization effect +$113.0B).

    6 tasks · 3 cost items · Months 3–15; annual updates thereafter
  8. 1.8
    Set hospital global budgets

    Each hospital gets an annual operating budget covering all UHP patients, negotiated with its regional office. In aggregate, hospital spending goes from $1.63T to $1.62T (price effect −$69.9B, utilization +$51.5B).

    7 tasks · 2 cost items · Months 6–18; annual negotiation thereafter
  9. 1.9
    Create the national formulary & negotiate drug prices

    A National Formulary and Pricing Board covers every FDA-approved drug with a negotiated price. Retail drug spending falls from $467.0B to $380.1B (price effect −$113.1B, utilization +$26.2B).

    7 tasks · 3 cost items · Months 0–18 for the initial formulary; continuous negotiation
  10. 1.10
    Create the Health Technology Assessment Institute

    An independent body that evaluates whether new services, devices, and drugs work better than existing alternatives, and recommends coverage and price. Removes ineffective services from the benefit package.

    4 tasks · 0 cost items · Months 0–18; continuous
  11. 1.11
    Rewrite insurance & benefits law

    Amend ERISA, the tax code, and the ACA so that employer plans and private insurance cannot duplicate UHP benefits, and so supplementary insurance is regulated.

    6 tasks · 0 cost items · Effective in stages with each enrollment wave
  12. 1.12
    Set up the new taxes

    IRS and Treasury implement the employer health payroll tax (7.5%), the household income-based premium (4.0% above an exemption), and the top-end surtaxes, each phased in with the enrollment waves.

    6 tasks · 15 cost items · Months 0–18
  13. 1.13
    Launch the displaced-worker program

    About 975,261 workers in insurance, billing, brokerage, PBMs, and related jobs will lose them over four years. The program pays wage replacement, wage insurance, training, and bridge pensions, and gives hiring preference at UHA and in health care.

    5 tasks · 4 cost items · Month 6 onward; benefits through Year 6
  14. 1.14
    Set data governance & privacy rules

    A single payer holds every American's claims history. Strict rules decide who can see it, for what purpose, and how it is protected.

    4 tasks · 0 cost items · Months 0–18