By NextBestFitWave 4: everyone
Cover the remaining adults, end job-based insurance, fold Medicaid into UHP, and switch every tax to its full rate.
- 100% of residents enrolled; uninsured rate effectively zero.
- No employer plans for UHP-covered services remain.
- State MOE payments flowing from every participating state.
- Ledger matches actual spending within ±5% by line.
Changes from chosen paths in this phase: 28
14 chosen solution paths (draft picks awaiting review) land in this phase. See every change.
- Coverage tied to residence, not job or income
- Decouple coverage from employment
- Cover all residents regardless of immigration status
- Cover the territories in the national program on the same terms as the states
- Eliminate out-of-network status
- Cut documentation and billing burden
- Every person registered with a primary care home
- Cover dental, vision, and hearing fully
- Legal wait-time guarantees
- Allow supplemental only (non-covered items)
- Private supplemental plans for extras
- Automatic exemptions and annual collection through taxes
- Waiting-time guarantees as a backstop
- Residence period before eligibility
Detailed steps
- 4.1Enroll everyone remaining
Adults 19–34 and anyone not yet enrolled join. About 80 million people.
2 tasks · 0 cost items · Year 4, Day 1 - 4.2End employer-sponsored insurance for covered services
Job-based coverage for UHP services ends for about 179 million people. Employer premium payments of $1.05T (private, federal, state & local) stop; the employer tax ($873.4B) is at its full rate. Worker premium contributions ($382.1B) end.
6 tasks · 11 cost items · Year 4 - 4.3Fold Medicaid and CHIP into UHP
Medicaid's acute-care and LTSS functions move to UHP. States begin paying the maintenance-of-effort amount ($345.7B a year) in place of their Medicaid share. Medicaid managed-care contracts end.
6 tasks · 5 cost items · Year 4 (dual eligibles and children earlier) - 4.4Coordinate with continuing payers: workers' comp, auto, VA, TRICARE, IHS
Several payment systems continue alongside UHP. UHP pays first for every resident and recovers costs from workers' compensation and auto/liability insurers. Workers' comp ($55.1B) and the medical portion of auto and property insurance ($55.3B) continue. The VA, military health system, and IHS remain delivery systems ($306.8B in federal programs).
6 tasks · 3 cost items · Years 1–4 - 4.5Switch every tax to its full rate
The employer tax reaches 7.5% and the household premium 4.0%. The trust fund starts building its 2-month reserve.
3 tasks · 1 cost items · Year 4