Phase 1: Enactment & build · Step 1.2

Create the UHP Trust Fund

Months 0–12 · Treasury (managing trustee), UHADiscuss this step

Pros & cons of this step

Pros

+Claims keep getting paid during shutdowns and debt-ceiling standoffs.
+Dedicated revenue is politically durable (cf. Social Security).

Cons

−Trust-fund 'insolvency' dates create recurring crisis politics (cf. Medicare HI).
−Permanent appropriation reduces Congress's annual control.

Stability for patients and providers vs. annual fiscal discipline.

medium confidence

Dependence on government competence and politics

Everyone's coverage depends on one agency's budget, IT, and political support. Underfunding, a shutdown, or bad rate-setting affects everyone, and there is no exit option.

Today

Risk is spread across thousands of plans; failures are local.

Under the plan

Concentrated risk; strong protections (trust fund, permanent appropriation) needed.

Who gains

No group directly

Who loses

Everyone, if governance fails

Magnitude: Low probability, very high impact.

UK
NHS waits rose sharply after years of below-trend funding growth (2010s).
Sources: NHS England (2025)
U.S. Medicare
Medicare has paid claims continuously since 1966, including through government shutdowns, because of its trust funds.
Sources: Medicare Trustees (2025)

Mitigations

Trust fund with permanent appropriation
Independent boards
Automatic stabilizers
Annual independent evaluation

Risk that remains: A future Congress can always cut funding.

Trade-off behind each cost item

Government public health+$157.6B
Holding this flat is a modeling choice; more public health spending is a separate decision.
Non-commercial research+$70.4B
Holding this flat is a modeling choice; more public health spending is a separate decision.
Employer Medicare payroll tax (1.45%)+$165.7B
Continues as before.
Worker & self-employed Medicare payroll tax+$254.1B
Continues as before.
Philanthropy, provider investment income, private research+$340.5B
Continues as before.
Federal employer Medicare payroll tax+$5.8B
Continues as before.
Medicare general revenue & net trust fund draw+$509.6B
Existing public money keeps flowing, now to UHP instead of separate programs.
Federal Medicare buy-in premiums for dual eligibles+$16.1B
Existing public money keeps flowing, now to UHP instead of separate programs.
Federal public health+$35.4B
Continues as before.
Other federal programs+$17.9B
Continues as before.
State & local employer Medicare payroll tax+$19.9B
Continues as before.
State & local health programs (CHIP share, hospitals, etc.)+$84.2B
Continues as before.
State & local public health+$122.1B
Continues as before.
Other state & local programs+$40.9B
Continues as before.
Federal budget view (one year, 2024 dollars)+$2.10T
Headline 'federal cost' numbers look enormous because private premiums become public taxes; the fair comparison is national spending and who pays.
Ten-year federal window (2027–2036)+$32.06T
Federal spending rises by tens of trillions of dollars over a decade while private spending falls by about as much; the totals are a shift in who pays, not mostly new spending.

Trade-off behind each system change

Medicare Board of Trustees & trust-fund insolvency projections
Clear early warnings; recurring 'insolvency' headlines continue to shape politics.
National Institutes of Health
Holding NIH flat isolates the coverage change; raising it would partly offset lost private R&D at a public cost.
CDC and state & local public health departments
Better surveillance data; health-data privacy concerns grow with public-health access.