By NextBestFitPhase 1: Enactment & build · Step 1.2
Create the UHP Trust Fund
Months 0–12 · Treasury (managing trustee), UHADiscuss this step
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.
Legal vehicle
Universal Health Act, Title VII; modeled on the Medicare HI and SMI trust funds.
Who does it
Treasury (managing trustee), UHA
When
Months 0–12
In this step
Tasks
4 tasks
Costs & calculations
16 cost items, each with its calculation
Trade-offs
2 pros · 2 cons · 2 trade-offs
Risks
2 risks with mitigations
What changes in the system
3 existing laws, programs, or institutions changed
Other countries
3 comparisons
Cost items
- Government public health$157.6B
- Non-commercial research$70.4B
- Employer Medicare payroll tax (1.45%)$165.7B
- Worker & self-employed Medicare payroll tax$254.1B
- Philanthropy, provider investment income, private research$340.5B
- Federal employer Medicare payroll tax$5.8B
- Medicare general revenue & net trust fund draw$509.6B
- Federal Medicare buy-in premiums for dual eligibles$16.1B
- Federal public health$35.4B
- Other federal programs$17.9B
- State & local employer Medicare payroll tax$19.9B
- State & local health programs (CHIP share, hospitals, etc.)$84.2B
- State & local public health$122.1B
- Other state & local programs$40.9B
- Federal budget view (one year, 2024 dollars)$2.10T
- Ten-year federal window (2027–2036)$32.06T
Biggest risk for this step
Recession cuts revenue. See risks.
Steps that depend on this one
None.
Sources: Medicare Trustees (2025)