Universal HealthcareBy NextBestFit
Phase 4: Wave 4: everyone · Step 4.2

End employer-sponsored insurance for covered services

Year 4 · Employers; DOL; OPM (FEHB); state & local governmentsDiscuss this step

Pros & cons of this step

Pros
  • +Job lock ends: people can change jobs, start businesses, or retire early without losing coverage.
  • +State and local governments shed large retiree-health (OPEB) liabilities.
  • +Employers exit the health-benefits business, which most say they don't want to manage.
Cons
  • −People with generous employer plans lose them These plans often feature broad networks and fast specialist access, because commercial rates make them the most profitable patients.
  • −Unions lose a central bargaining issue and the institutional role of running health funds.
  • −Employers lose a recruitment tool (rich benefits).
  • This is where the trade-off between fast access for employer-insured people and equal access for everyone is sharpest. Under one price for every patient, providers no longer prioritize the commercially insured. Their waits for elective specialist care will likely lengthen modestly, while Medicaid and uninsured people's waits shorten substantially.
medium confidence

Speed of access for people with employer insurance

Today, commercially insured patients are the most profitable patients, so they get scheduled first. Under one price for everyone, that advantage disappears. Employer-insured people will likely wait somewhat longer for non-urgent specialist care, especially in Years 1–5.

Today
Private insurers pay hospitals about 2.2–2.5x Medicare and physicians about 1.4x. Practices limit Medicaid slots and prioritize commercial patients. New-patient waits across 15 large metros already average about a month.
Under the plan
Every patient pays the provider the same rate. Physician-visit demand rises about 12% ($113.0B a year), while supply grows slowly. The commercially insured lose their place at the front of the line.
Who gains
  • Medicaid enrollees
  • The uninsured
  • Underinsured people who delay care due to deductibles
Who loses
  • People with generous employer coverage in specialties with tight supply (dermatology, orthopedics, psychiatry, gastroenterology)

Magnitude: Likely days to a few weeks longer for elective specialist care in Years 1–5 for the previously commercially insured, if capacity investment lags. No predicted change for emergency or cancer care, which is triaged by urgency.

  • U.S. Medicaid
    Only about 74% of physicians accept new Medicaid patients versus 96% for private insurance; secret-shopper studies find Medicaid callers get appointments much less often. Availability rose when Medicaid fees rose, so the gap is about price, not public coverage itself.
    Sources: Holgash & Heberlein, Health Affairs Forefront (2019); Polsky et al., NEJM (2015)
  • U.S. Medicare
    About 88% of physicians accept new Medicare patients, close to private insurance. Medicare is public, pays roughly Medicare rates by definition, and its access is broadly comparable to commercial. UHP pays 112–120% of Medicare.
    Sources: Holgash & Heberlein, Health Affairs Forefront (2019)
  • Canada
    Median 28.6 weeks from GP referral to treatment in 2025, ranging from 19.2 weeks in Ontario to 60.9 in New Brunswick. Driven by low capacity (fewer MRI units, operating-room time limited by global budgets) and the ban on private duplicative insurance.
    Sources: Fraser Institute (2025)
  • United Kingdom
    About 7.4 million cases on NHS England's waiting list in 2025; about 59% treated within 18 weeks against a 92% standard. Long-term underinvestment and post-COVID backlog.
    Sources: NHS England (2025)
  • Germany
    Short waits overall, but privately insured patients (about 11%) get specialist appointments substantially faster than statutory-insured patients because physicians earn more from them. The same dynamic as U.S. commercial vs. Medicaid.
    Sources: European Observatory on Health Systems and Policies (2020)
  • Taiwan
    Single payer with very short waits and high visit volumes, but short physician visits (often a few minutes) and high physician workloads.
    Sources: Taiwan National Health Insurance Administration (2024)
Mitigations
  • Pay rates above Medicare (120% hospitals, 112% physicians) so participation matches Medicare's.
  • Legally binding wait-time guarantee with vouchers to any provider.
  • $12.0B a year in workforce investment and $50.0B in capacity capital.
  • Keep U.S. capital spending at today's level: the U.S. has far more MRI/CT units per capita than Canada and the UK.
  • Expand nurse practitioner and PA scope; telehealth.
Risk that remains: Training takes years. If demand grows faster than supply, waits rise for everyone, and the employer-insured, who wait least today, notice most. This is the most likely politically fatal failure mode.
medium confidence

Labor market: job lock and entrepreneurship

Health coverage no longer depends on employment, so people can change jobs, start businesses, retire early, or work part-time without losing coverage.

Today
Many workers stay in jobs for the health insurance.
Under the plan
Coverage is portable and unconditional.
Who gains
  • Workers
  • Entrepreneurs
  • Early retirees
Who loses
  • Employers who relied on benefits for retention
  • Labor supply may fall slightly as some people retire earlier

Magnitude: Qualitative to moderate.

Risk that remains: Slightly lower labor-force participation among 55–64-year-olds.

Jobs affected by this step

Trade-off behind each cost item

Trade-off behind each system change