Universal HealthcareBy NextBestFit
Phase 1: Enactment & build · Step 1.5

Define the benefit package & cost sharing

Months 0–12 · Congress (statutory categories); UHA Chief Medical Officer; HTA InstituteDiscuss this step

What is covered

How broad is the benefit package?

The plan chooses
Hospital, physician, outpatient, mental health and substance use, maternity and newborn, prescription drugs on the national formulary, lab and imaging, rehabilitation, adult and pediatric dental (preventive, restorative, dentures, medically necessary orthodontics), vision (exams and basic eyewear), hearing (exams and hearing aids), home- and community-based long-term services, and the clinical component of nursing-facility care. Excluded: over-the-counter products, cosmetic procedures, premium eyewear and hearing aids, nursing-home room and board (income-tested contribution), and services the technology-assessment body finds ineffective.

Leaving dental, vision, and hearing out would keep a large out-of-pocket market and leave seniors with today's gaps (traditional Medicare excludes them). Long-term care at home is included because Medicaid's spend-down rules force people into poverty to qualify, which is incompatible with universality. Room and board are excluded, as in Canada, to avoid paying for housing through the health budget.

Comprehensive incl. home-based LTC (chosen)

As described.

Pros
  • +Out-of-pocket spending falls from $556.6B to about $197.3B
  • +Ends Medicaid's asset spend-down for home care
Cons
  • −The most expensive option Dental, home health, and HCBS together add about $111.4B in utilization in the central case.
  • −The direct-care workforce (home aides) is already short, so waits for home care are likely

Medicare-equivalent benefits

Hospital, physician, and drugs only.

Pros
  • +About $110–150B a year cheaper
Cons
  • −Keeps dental, hearing, and vision costs on households
  • −Seniors would lose Medicare Advantage extras with nothing in their place

Full LTC including room and board

As in the Medicare for All Act, which covers institutional LTC.

Pros
  • +Complete protection from catastrophic long-term care costs
Cons
  • −Adds roughly $40–60B a year and creates an incentive to institutionalize
  • −Turns the health program into a housing program

Precedent: Japan and Germany use separate social LTC insurance programs (Kaigo Hoken, Pflegeversicherung) with their own payroll contributions.

What this choice gives up
  • Lower total cost from a narrower package.
  • Full institutional long-term-care coverage.
Sources: U.S. Senate (2023); KFF (2024)

Cost sharing at the point of care

Should patients pay deductibles, copays, or coinsurance?

The plan chooses
No deductibles, copays, or coinsurance for covered services. A $0 / $5 / $15 prescription copay schedule (generic / preferred brand / non-preferred brand), capped at $200 a year per person and waived below 200% of the poverty line, is kept as a standby option Congress can switch on if utilization exceeds the costly-case projection. It is off in the central estimate.

Cost sharing reduces both low-value and high-value care (RAND Health Insurance Experiment). Its administrative cost (eligibility checks, collection, bad debt) offsets much of its saving under a single payer. Every dollar of induced demand is counted in the utilization effect, $349.6B in the central case.

Zero cost sharing (chosen)

Free at the point of service.

Pros
  • +No one skips care because of cost Today about 1 in 4 adults report skipping care because of cost.
  • +Simplest to administer: no bills to patients at all
  • +Ends medical debt from covered care
Cons
  • −Highest induced demand The utilization effect is $349.6B a year in the central estimate and $564.0B in the costly case.
  • −More low-value visits compete with high-value care for the same appointment slots

Precedent: UK NHS (except prescriptions in England), Canada (physician and hospital care).

Capped copays (Sweden/Japan/France style)

Small per-visit fees with a low annual cap and exemptions for low-income and chronically ill people.

Pros
  • +Reduces induced demand by roughly 3–6%
  • +Raises some revenue
Cons
  • −Requires billing infrastructure for every visit
  • −Deters the poor most, even with exemptions, because of the hassle

Precedent: Sweden (about $20–40 per visit, with a SEK 1,450 annual cap); Japan (30% coinsurance with monthly caps); France (ticket modérateur, mostly covered by supplementary mutuelles).

High-deductible catastrophic coverage

UHP covers everything above, say, 5% of income.

Pros
  • +Much lower public cost
Cons
  • −Doesn't solve underinsurance, which is a goal of the plan
  • −Keeps billing complexity for everyone

Precedent: Singapore's MediShield Life sits atop mandatory medical savings accounts (Medisave).

What this choice gives up
  • A price signal that discourages marginal use.
  • The $50–100B a year that moderate cost sharing would save.
Sources: RAND Corporation (1986); Finkelstein, Baicker et al., NEJM / QJE (2013)

Contested services: abortion and gender-affirming care

Does UHP cover services subject to federal funding restrictions today (the Hyde Amendment)?

The plan chooses
The plan leaves this to an explicit congressional vote rather than hiding it. Option A: cover them, which repeals Hyde for UHP. Option B: exclude them from UHP while allowing states to fund them through their own supplementary programs. The cost difference is under $1B a year either way, so it doesn't change the ledger. The real trade-off is political: Option A risks losing votes from members who oppose federal abortion funding, and Option B means UHP is not universal for these services in some states.

A single national payer means a single national answer. Today the answer varies by insurer and state. Making that explicit is more honest than leaving it to agency discretion.

Cover (repeal Hyde for UHP)

As in the Medicare for All Act.

Pros
  • +Uniform coverage nationwide
Cons
  • −Loses votes; likely litigation over conscience protections

Exclude; allow state supplements

Hyde applies; states may fund with their own money.

Pros
  • +Broader coalition
Cons
  • −Coverage differs by state, and many people lose coverage they have now under private plans
What this choice gives up
  • Either nationwide uniformity or political breadth.
Sources: U.S. Senate (2023)