Action Jackson's BOND Plan: The Health Care Bill Washington Refuses to Consider

Benefits Owed, Not Denied. Zero at the counter, your doctor stays your doctor, and I print the tax table before you vote on it.

Executive Summary

America America spends $5.7 trillion a year on health care, more than any nation on earth, and finishes last among ten wealthy countries on access, fairness, and lifespan.

That money is not missing. It leaves your paycheck every two weeks as a premium you never voted on, and a third of it vanishes into billing, prior authorization fights, and insurance overhead no patient asked for.

The Action Jackson BOND (benefits owed, not denied) Health Care Plan replaces eighteen hundred payers with one and hands every citizen and lawful resident a card covering doctor, hospital, mental health care, and prescriptions. Nothing owed at the counter. Same private practices and hospitals you use today.

Congress’s nonpartisan budget office studied systems like this: spending stays flat or falls, everyone gains coverage, most households pay less.

Everybody covered. Nobody goes broke because they got sick. No other plan in American politics can promise that.

The design is the problem

Read this before someone tells you it costs too much

Half of us cannot pay a five hundred dollar medical bill

Right now, today, in July of 2026, about half of American adults could not pay an unexpected five hundred dollar medical bill out of pocket. One in five could not pay it at all. Another one in five would put it on a credit card and carry the interest. Another five percent would borrow the money from a bank, a payday lender, or family.

Sit with that number for a second, because you are one of those people, or you love one.

Forty three percent of American adults did not take their medication as prescribed last year because of the price. Twenty seven percent never filled the prescription their doctor wrote. Nineteen percent cut the pills in half or skipped doses to stretch the bottle. Household medical debt in this country runs to at least two hundred and twenty billion dollars, and roughly four in ten adults carry some form of health care debt once you count the credit cards, the bank loans, and the money borrowed from family.

Your employer paid twenty thousand one hundred and forty three dollars into your family health plan last year. You paid another six thousand eight hundred and fifty out of your paycheck. The average family premium hit twenty six thousand nine hundred and ninety three dollars in 2025. Economists across the political spectrum agree the employer’s share comes out of your wages. You never see the money. You never voted on the amount. You have no appeal.

Here is where the country stands this summer. The enhanced subsidies that held marketplace premiums down expired on December 31, 2025, after the Senate voted on competing approaches in December and advanced none of them. About twenty four million Americans had marketplace coverage in 2025, and roughly twenty two million of them received those enhanced credits. Their average annual premium payment more than doubled, climbing one hundred and fourteen percent, from eight hundred and eighty eight dollars in 2025 to one thousand nine hundred and four dollars in 2026. Marketplace insurers proposed a median rate increase of eighteen percent for this year, the largest since 2018.

The 2025 reconciliation law, the One Big Beautiful Bill Act, cut more than a trillion dollars from Medicaid and the marketplaces, and the Congressional Budget Office projects ten million more Americans without coverage through 2034. Roughly twenty six million Americans already had no health coverage before any of this landed.

On January 8, 2026, the House passed a three year extension of those subsidies by a vote of two hundred and thirty to one hundred and ninety six, with seventeen Republicans crossing the aisle. The bill went to the Senate. It has not moved. Ten states built their own temporary subsidy programs to hold the line for their residents. Check the current status before you argue about it with anyone, because this fight is live and the facts move.

The system is not failing. The system is working exactly as designed, and the design is the problem.

I am going to show you the whole plan. Every number. Every objection. You deserve to see all of it before you decide.¹

Why free Is the right engineering, and not a gift

Easy to understand summary of this section: Your copay was supposed to make you skip the visit you don’t need. Two of the largest studies ever run proved it does the opposite, scaring sick people away from the care they do need and hitting the poor and the ill hardest of all. So here is the honest deal: the deductible, the copay, and the surprise bill are gone forever, the premium your employer withholds every two weeks (already is happening) becomes a tax that replaces it, and most families pay less in total than they do right now. You never owe a dime at the counter again.

Start with the thing almost every American health plan gets backward.

Deductibles and copays rest on a theory. The theory says free care invites people to overuse doctors, so a price at the counter makes you skip the frivolous visit and keep the necessary one. The theory sounds sensible. The theory has been tested twice, rigorously, and the theory is wrong.

The RAND Health Insurance Experiment ran from 1974 to 1982 and randomly assigned families to health plans ranging from completely free care to ninety five percent coinsurance. It remains the largest randomized health insurance experiment ever conducted in the United States, the closest thing this field has to a controlled experiment on a nation.

Its central finding: cost sharing cut the use of highly effective care and less effective care in roughly equal proportions.

Patients did not trim the waste. They trimmed everything, evenly, because a man sitting at home at two in the morning with a pain in his chest cannot tell you whether the visit is high value or low value. Figuring that out is what a doctor is for. Charging him twenty dollars to find out does not make him smarter. It makes him wait until Tuesday.

Free care in that experiment improved blood pressure control, dental health, vision, and serious symptoms. The health harms of cost sharing landed on exactly one group. Low income people in poor health. That is not a footnote buried in an appendix. That is the population the entire system exists to protect.

Forty years later, researchers studied a large firm that moved every single employee from a free health plan onto a high deductible plan. Company wide spending dropped twelve to fourteen percent. The researchers went hunting for the reason. They found no evidence of price shopping. They found people buying fewer units of care across the board, high value care along with low value care, with somewhat deeper cuts in imaging that was likely low value. Mostly they found less care.

Here is the finding that should end this argument. The sickest quarter of those employees cut their spending by eighteen to twenty two percent. Those employees blow through the deductible by March. For nine months of the year their next dollar of care costs them almost nothing. They cut anyway, because the deductible frightened them.

The price signal does not discipline how you use your doctor. The price signal frightens sick people away from their doctor.

Your copay is a rationing device. It rations by fear. It rations hardest against the poor and the ill, which means it rations against the exact people the money was collected to help.

Remove it. Not as charity. As correct engineering.

The important take-a-way is to know tat care costs you nothing when you need it. The country still pays the bill through taxes.

I want you to understand why I am being this precise with you, because imprecision on this one point has killed more American health reform than any lobbyist ever did. Here is the autopsy.

In 2011 Vermont passed a single payer framework designed with help from Harvard economists. The framework sailed through. The financing waited for later. Governor Shumlin’s team ran fourteen separate financing concepts and never once got the payroll tax below double digits. The version they finally published demanded an eleven and a half percent payroll tax and income taxes reaching nine and a half percent. The program would have cost four point three billion dollars in its first year and required somewhere between two point six and two point eight billion dollars in new state tax revenue, depending on which analysis you read, against one point seven billion the state expected to collect in total. Every analysis called it a one hundred and fifty one percent increase in state taxes. Shumlin killed his own signature achievement in December of 2014.

Now here is the part nobody remembers. Every serious study of that plan, the 2011 Harvard analysis, a 2013 UMass analysis, and the state’s own 2014 modeling, concluded Vermont would spend less overall, and that costs would fall for roughly ninety percent of Vermont families earning under one hundred and fifty thousand dollars. The math worked. The politics died anyway, because the promise arrived three years ahead of the price tag.

So I will make you the honest promise, and I will make it in one paragraph you can hold anyone to.

No American family pays anything when they get sick. No premium. No deductible. No copay. No coinsurance. No surprise bill from an anesthesiologist you never met. Nobody in this country goes bankrupt because they got cancer. The large majority of households pay less in total than they pay right now, and you get to look up your own household number before you vote on it.

The money is already leaving your paycheck

Easy to understand summary of this section: America spends $5.7 trillion a year on health care, more than anyone on earth, and finishes dead last among ten wealthy nations on access, fairness, and how long our people live. The government already pays the biggest share of that bill, and Congress’s own budget office says a single-payer system wouldn’t raise what the country spends. The money is already leaving your paycheck every two weeks. It just leaves through a premium nobody ever voted for.

The United States spent roughly five point seven trillion dollars on health care in 2025. Eighteen point four percent of everything this economy produces. We are on track for nine trillion dollars and twenty point six percent of the economy by 2034. Per person, we spent fifteen thousand four hundred and seventy four dollars in 2024, and more now.

For that money we buy last place.

The Commonwealth Fund compared ten wealthy nations in 2024 and ranked the United States tenth of ten overall. Last on access. Last on equity. Last on health outcomes. Americans live the shortest lives and suffer the most avoidable deaths in the group. American life expectancy peaked at seventy nine years in 2024, about two years below the average of developed nations and third lowest among all of them, ahead of only Mexico and Turkey.

The federal government was already the single largest sponsor of American health spending in 2024, at one point seven trillion dollars, a thirty one percent share. Total federal health spending climbs from roughly two point four trillion in 2024 to four point three trillion by 2033. Whether you signed up for it or not, you are already living in a country where the government pays the biggest share of the health bill.

This is not a spending problem. This is an allocation problem, and the allocation is already mostly public.

Congress’s own nonpartisan budget office settled the arithmetic. Studying five different single payer designs, the office projected that national health spending in 2030 would land somewhere between seven hundred billion dollars lower than current law and three hundred billion higher. Federal spending would rise by one and a half to three trillion dollars, because private spending converts into public spending.

Read that twice, because it is the whole ballgame. The country does not spend more. The check has a different name on it.

Your money already leaves your paycheck every two weeks. It leaves through a premium, which nobody voted for. A premium is a tax without representation.

How the system works: public financing, your health card and private doctors

Easy to understand summary of this section: Nothing gets nationalized here. Your doctor stays your doctor, your hospital stays privately owned, and one payer simply replaces the eighteen hundred billing entities your doctor’s office is on the phone with right now. Every citizen gets a card at birth that covers everything from your primary care visit to your prescriptions to your mental health treatment, with no forms, no income check, and nothing owed at the counter. You keep a private market for extras, and the 154 million Americans covered through work never hear that their plan is illegal.

Public financing. Private delivery. Those four words carry this entire plan, and almost nobody in American politics says them clearly.

Britain owns its hospitals and employs its doctors. This plan does neither.

Australia ranked first overall in that same ten nation comparison, and Australia runs a universal public payer alongside privately delivered care, with supplementary private coverage permitted on top. Taiwan built a single payer system from scratch in 1995, moved from fifty nine percent of its people covered to ninety two percent inside of one year, reached ninety nine point nine percent today, and runs the whole thing on administrative overhead of roughly one to two percent.

Nothing here gets nationalized. Your doctor stays your doctor. Your hospital stays privately owned, nonprofit, religious, or for profit, exactly as it is today.

One payer replaces the current field, which runs somewhere between nine hundred and eleven hundred health insurance companies, and closer to eighteen hundred separate billing entities once you count third party administrators and government programs. Your doctor’s office maintains a working relationship with every one of them. Somebody in that office is on the phone right now.

Your health card: Everybody gets a card. Nobody fills out a form.

Every American citizen and lawful resident gets enrolled at birth or on admission. No applications. No income verification. No annual redetermination. No churn.

Eligibility bureaucracy is not a safeguard. Eligibility bureaucracy is a cost center whose entire function is to remove people from coverage. Every dollar spent deciding whether you qualify is a dollar nobody spent treating you, and the machinery misfires constantly. The Medicaid unwinding stripped coverage from millions of Americans over paperwork, not over eligibility. Those people qualified. They lost coverage anyway.

You get a Health Security number and a card. Nothing else determines whether you have it. Not your employer. Not your income. Not your marriage. Not whether you paid last month.

Taiwan proved this works on the ground. Taiwan carried coverage from fifty nine percent of its people to ninety two percent inside of twelve months, and reached ninety nine point nine percent from there.

Because of your card, everything below carries zero cost at the point of service, on the evidence you have now read.

Primary care and preventive care. Hospital care, inpatient and outpatient. Emergency care and ambulance rides. Specialty care with no referral gatekeeping and no network restrictions. Mental health and substance use treatment at full parity, with no cap on visits. Maternity care, prenatal through delivery and postpartum for a full twelve months. Pediatric care including developmental and behavioral. Prescription drugs on a national formulary. Laboratory work, imaging, diagnostics. Rehabilitation and durable medical equipment. Palliative care and hospice. Dental. Vision. Hearing. Reproductive health as governed by law in each state.

Beginning in year six, long term care phases in.

Long term care is the benefit American families need most and the one no financing mechanism in this country has ever solved. Middle class families liquidate a lifetime of savings and then spend themselves down into poverty to qualify for Medicaid so their mother can have a nursing home bed. We built a wealth destruction machine and pointed it at the elderly.

The budget office found that its most generous option, the one including long term care, is the only design that pushes national health spending above current law, by roughly four point four percent. So we phase it in last. We finance it through a separately scored dedicated contribution. We put home and community based care ahead of institutional care, which families prefer and which costs less. If the long term care contribution stalls in Congress, the core system keeps running.

Private services: Private carriers may sell coverage for services outside the core benefit and for amenities like a private room. Private carriers may not sell duplicate coverage for core benefit services, because duplicate coverage builds a two tier line where money buys you priority for identical care. Australia and France thread this exact needle and their systems work.

You keep a private market. You keep choice. You keep an exit ramp if you want more.

This also destroys the single most effective attack line in American health politics. The government is banning your insurance. That line works because it is currently true of the leading proposals in Congress. One hundred and fifty four million Americans under sixty five have coverage through work. Most of them like it. Telling one hundred and fifty four million people their plan is now illegal is a concession speech with a policy paper stapled to the front.

Where the money comes from

Easy to understand summary of this section: Nearly every dollar to pay for this already exists. It just moves. Medicare, Medicaid, and the rest of what taxpayers already spend gets redirected, the tax break for employer insurance ends, employers pay less than they pay today, and your premium becomes a progressive contribution that starts at zero for lower-income families. The rest comes from waste. America burned $812 billion on health care paperwork in 2017 while Canada spent a fraction of that per person, and we pay 2.78 times what other wealthy nations pay for the same drugs.

Nearly every dollar already exists. Watch it move.

You stop paying employer premium contributions. You stop paying worker premium contributions. You stop paying deductibles, copays, and coinsurance. You stop paying individual market premiums. You stop getting balance bills and surprise bills.

Here is what replaces all of it.

First, existing public spending gets redirected. Medicare, Medicaid, CHIP, marketplace subsidies, the VA and TRICARE which keep operating as delivery systems, federal employee health benefits, the Indian Health Service, and state Medicaid dollars under a maintenance of effort requirement. This is the largest single source of financing in the plan and it requires zero new taxation. You already pay for this.

Second, the tax break for employer health insurance goes away.

That break is regressive, invisible, and inflationary. Roughly sixty percent of its benefit flows to households above four hundred percent of the federal poverty line. Because it has no ceiling, it pushes people toward more expensive coverage than they would otherwise buy, which has plausibly raised costs across the whole system. Economists at Cato and economists at Brookings have argued for ending it or capping it for decades, for the same reasons, from opposite directions. Universal coverage erases its purpose entirely.

The Joint Committee on Taxation scored the income tax portion at roughly one hundred and ninety billion dollars in fiscal 2021. Treasury put it at two hundred and fifty two point four billion in 2024. Counting income and payroll effects together, the Tax Policy Center estimated two hundred and ninety nine billion in 2022. Treasury projects three point nine trillion in forgone income tax across 2025 through 2034, and five point nine trillion including payroll effects, averaging roughly five hundred and ninety billion a year. Whether this ranks as the single largest tax expenditure in the code depends entirely on whether you count payroll effects. On the income only ranking it comes in third, behind retirement exclusions and the preferential rate on capital gains. Counting payroll, it comes in first.

Third, an employer health security contribution. A payroll contribution set below what the average employer pays for coverage today. Employers who cover their people watch their health costs fall. Employers who cover nobody start contributing, which ends the free ride they take on everyone else. Firms below a payroll threshold pay reduced rates or nothing.

Fourth, an individual health security contribution. Progressive. Zero below two hundred percent of the federal poverty line. Graduated above it.

And now the procedural rule I will not bend on. The rate schedule appears in the bill itself, in dollars, with a public household calculator, before a single member of Congress casts a single vote. Vermont did not fail at arithmetic. Vermont failed at sequence.

Fifth, contributions on unearned income above a threshold. Health security is a benefit of citizenship and gets financed on citizenship’s terms.

Sixth, the savings, and I am going to score them conservatively on purpose.

American insurers and providers spent eight hundred and twelve billion dollars administering health care in 2017. Two thousand four hundred and ninety seven dollars per person. Thirty four point two percent of everything the nation spent on health that year. Canada spent five hundred and fifty one dollars per person on the same functions, seventeen percent of its total. Insurer overhead alone ran two hundred and seventy five point four billion dollars here against five point three six billion there. Of the American figure, forty five billion went to administering government programs and two hundred and twenty nine and a half billion went to private insurer overhead and profit. Matching Canadian administrative levels would have freed more than six hundred billion dollars in that single year. Taiwan runs its whole program on one to two percent.

Score half of that achievable gap. Half still transforms the balance sheet of the United States.

On drugs, American prices average two point seven eight times what thirty three other wealthy countries pay. Brand name originator drugs run four point two two times higher at gross prices, and at least three point two two times higher even after adjusting for the rebates American manufacturers pay back. Among those thirty three comparison countries, the United States accounts for roughly twenty four percent of the drug volume and sixty two percent of the drug spending.

Generics are the exception. American unbranded generics run about sixty seven percent of comparison country prices, and generics make up ninety percent of American prescription volume. The target here is brand name pricing. The generic market already works.

The five claims, stated so you can check them

Easy to understand summary of this section: Most single-payer plans quietly pay hospitals Medicare rates, which strips away forty percent of their revenue and closes rural hospitals. This plan refuses, funding a rate between Medicare and commercial and paying for it out of paperwork and brand-name drug prices instead. Maryland already ran this experiment and held hospital spending growth to 1.4 percent while cutting hospital-acquired conditions by 43 percent, and doctors come out ahead here, because the budget office projects clinician pay goes up while the overhead of fighting insurance companies goes down.

Total national health spending stays roughly flat or falls. The budget office range runs from seven hundred billion lower to three hundred billion higher.

Federal spending rises one and a half to two and a half trillion dollars, offset by private spending that stops.

The large majority of American households pay less in total than they pay today.

Some households pay more. Chiefly high income households, and households now receiving unusually rich employer coverage for which they pay little directly.

Nobody goes bankrupt from illness.

That fourth claim is where honest people lose elections. I am saying it out loud anyway, and I am putting it in the bill. Vermont is what happens to people who go quiet on that sentence.

Paying doctors and hospitals without destroying them

Most single payer proposals quietly cheat right here, and that is why hospitals fight them to the death.

Pay every provider Medicare rates and hospitals lose roughly forty percent of what they collect from commercial insurers. Rural hospitals close. Safety net hospitals close. Academic medical centers close. That is not a lobbyist talking point handed to you by a public relations firm. That is subtraction.

So this plan refuses to do it. This plan funds a rate between Medicare and commercial, and recovers the difference from administration and from brand name drugs. The budget office modeling confirms the approach. Even its higher payment options produce national savings, because the administrative and pharmaceutical waste runs that deep.

Maryland already ran this experiment

Maryland has operated the only all payer hospital rate regulation system in the country for decades. Since July of 2014, every acute care hospital in Maryland has run on a global budget, a fixed annual revenue amount set in advance based on population and inflation.

Watch what a global budget does to the incentive. Under fee for service, every additional admission is revenue, so the hospital wants your body in the bed. Under a global budget, every avoidable admission is a cost. The hospital suddenly wants you healthy and at home.

The results are not theoretical. In the first three years, per capita hospital spending growth held to one point four percent against a federal target of three point five eight percent. Over five years the state held hospital expenditure growth to roughly one point nine percent annually, saved Medicare one point four billion dollars on hospital spending and eight hundred and sixty nine million on total cost of care, with growth rates running eight point seven four and two point seven four percentage points below the nation. Readmissions fell six point one percent against a target of four point nine. Hospital acquired conditions fell forty three point three percent. Medicare’s own evaluation found the model reduced hospital spending without shifting costs into unregulated settings, with a slight shift in the site of care for Medicare patients.

Now I am going to give you the strongest objection to Maryland, because you will hear it and you should hear it from me first.

A separate study estimated nine hundred and seventy five million dollars in Medicare savings over five years and found no overall savings for commercial plan members, because rising professional spending outside the hospital partially offset the hospital savings. A hospital global budget is not a total cost of care budget.

The people who found that problem already fixed it. Maryland moved to the Total Cost of Care Model in 2019, the first federal model holding an entire state accountable for the total cost of care for Medicare beneficiaries, and that model was on course to save Medicare over a billion dollars by the end of 2023. This plan adopts the Total Cost of Care design. Rates get set by state commissions inside federal bands, negotiated every year with hospital associations and clinician groups.

Doctors do better under this plan. Analysts writing in Health Affairs took the budget office data and calculated that clinician payments rise under all five of the single payer scenarios modeled, translating to an additional thirty nine thousand eight hundred and sixteen to one hundred and fifty seven thousand four hundred and twelve dollars in revenue per practicing physician, with practice overhead shrinking on top of it. Those authors disclose that they are themselves physicians, and to their credit they wrote that such a windfall may be excessive for some providers. Take the finding and take the caveat together. The direction is the point. The budget office does not project a pay cut for doctors.

The reason sits in the overhead. American physician practices burn enormous sums fighting insurance companies. Mean overhead runs about fifty six percent of revenue in American practices against twenty four point seven percent reported by Canadian physicians, a gap worth roughly one hundred and eighty eight thousand dollars per physician per year.

The honest caveat, which the researchers state themselves: those figures include items unrelated to billing, like malpractice insurance, which costs more here for its own reasons. So one hundred and eighty eight thousand dollars marks the ceiling on the billing dividend. The number is not a pure measure of billing waste. The number stays enormous.

The design is one national fee schedule, updated annually, negotiated with organized medicine. No prior authorization for the overwhelming majority of services. No network contracting. No medical necessity denials outside a narrow, published, appealable list. One form.

Primary care, psychiatry, and geriatrics draw an explicit payment premium, because this country is structurally short of exactly the clinicians who prevent expensive emergencies from ever happening.

Rural hospitals get a floor, not a funeral. Global budgets stabilize rural hospitals. Medicare has already tested this through the Pennsylvania Rural Health Model and extended global budgets into rural communities through the Community Health Access and Rural Transformation Model.

A guaranteed revenue floor lets a rural hospital stop chasing volume it does not have and start serving the community in front of it. COVID showed every American how fragile a volume dependent hospital becomes the moment the volume stops.

The plan creates a Rural Health Security Fund, sets a revenue floor tied to the population served, with services billed taken out of the formula, and bars closing a sole community provider without a federally reviewed continuity of care plan.

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Drugs, and the innovation question you deserve an answer to

Easy to understand summary of this section: One national drug formulary with prices negotiated against what six peer nations pay, and because cutting drug revenue does cut research, we triple the NIH and pay for it out in the open. Malpractice reform (not eliminating your right to sue, but appropriate reform) goes in the bill too, offered to doctors as part of the deal. Then the warning nobody quotes: the budget office found that some of the projected savings come from care people want and cannot get, so this plan builds doctors, residency slots, and clinics starting in year one and does not finish covering everyone until year five.

One national formulary, with a transparent and appealable coverage process. Prices set by negotiation, backstopped by an international reference price keyed to the average of the six largest peer economies. Generics stay in the current market, which already beats peer country prices.

Here is the objection at full strength. Cutting pharmaceutical revenue cuts pharmaceutical research at the margin. Anyone who denies that is selling you something. The magnitude is contested, the industry’s own estimates serve the industry, and the direction is not seriously disputed among economists.

So we replace part of the lost private return with public investment. Triple the National Institutes of Health, now running roughly forty seven to forty eight billion dollars. Expand the advanced research agency for health. Add advance market commitments for antibiotics and vaccines, where private markets already fail on their own terms and everybody knows it. Add prize money for defined targets.

Cost, roughly eighty to one hundred and twenty billion dollars a year. Score it as a cost, because that is what it is. A plan pretending research is free mirrors a plan pretending coverage is free. I refuse to write either one.

Malpractice reform, in the bill, on purpose. Defensive medicine is real, expensive, and badly measured. A federal safe harbor, where following clinical practice guidelines creates a rebuttable presumption of due care, protects your right to sue for actual negligence and kills the incentive to order a third CT scan for the chart. Pair it with a no fault compensation fund for avoidable adverse events, modeled on the vaccine injury program, which pays injured patients faster and more reliably than tort litigation ever has.

I am a trial lawyer. I have handled and tried to verdict million dollar medical malpractice cases. Yes, doctors and health care facilities make mistakes but, I am telling you this concession belongs in the bill, offered to physicians and to political parties in exchange for their acceptance of the payment structure, and I am telling you it is also good policy on its own merits. Both things are true. That is what a deal looks like.

The thing that kills this plan. The budget office issued one warning that nobody quotes, buried inside a two hundred and eight page working paper. The supply of health care under a single payer system would not meet all of the new demand, thereby constraining the increase in national health spending.

Read that sentence again slowly. Part of the projected savings comes from care people want and cannot get.

Coverage without capacity produces waiting rooms. Waiting rooms produce headlines. Headlines produce repeal.

So capacity investment starts in year one and universal coverage completes in year five. The gap between those two dates is deliberate and it is the most important design decision in this document.

Lift the 1997 cap on federally funded residency slots, which Congress has chipped at with twelve hundred additional slots and never repealed. Add twenty five thousand slots over ten years, weighted toward primary care, psychiatry, and geriatrics. Forgive student loans in full at five years for clinicians practicing in shortage areas. Set a federal floor for what nurse practitioners, physician assistants, pharmacists, and dental therapists are allowed to do, which is the fastest capacity increase available to this country, and pay for that fight with the malpractice safe harbor. Triple the investment in community health centers, among the most cost effective delivery mechanisms in American medicine and already bipartisan in Congress. Reimburse telehealth permanently at parity with interstate licensure compacts. Fast track visas for foreign trained physicians and nurses who complete American certification.

That last one is politically hard. It is medically necessary. Both facts hold.

Ten years, sequenced so it cannot fail all at once

Easy to understand summary of this section: Ten years, in order. Year one builds the system and an independent board insulated like the Federal Reserve. Year two covers kids and everyone 55 to 64, which pulls the sickest people out of the commercial pool and drops private premiums for everyone still in it, so business becomes an ally before anyone asks it to give up anything. Year three fixes prices and makes primary care and mental health free for every American, years four and five cover everybody else, and long-term care phases in through year eight. Years nine and ten review and adjust.

Year one, we build. Congress passes the statute with the financing inside it and the household contribution schedule printed in the bill. We establish a National Health Security Board, independent, staggered fourteen year terms, presidential appointment and Senate confirmation, insulated the way the Federal Reserve is insulated. Every rate decision and formulary decision gets published with the reasoning behind it. We build enrollment, the claims system, and a national claims database. Capacity money starts moving.

Year two, we cover the ends of life. Everyone under nineteen. Everyone fifty five to sixty four.

This is the load bearing move in the entire rollout and I want you to understand exactly why. Children cost little and covering them is politically unassailable. Adults fifty five to sixty four are the sickest, the most expensive, and the likeliest to be uninsured or underinsured before Medicare eligibility arrives.

Pull that cohort out of the commercial risk pool and private premiums fall for everybody still in it. Employers watch their health costs drop in year two, before anyone asks them to give up a thing. Business becomes an ally at the exact moment the coalition is most fragile.

You do not ask industry to sacrifice for a promise. You pay it first.

Year three, we fix the prices. All payer rate setting goes live nationally on the total cost of care design. Hospital global budgets phase in. The national fee schedule replaces contracted rates. Drug reference pricing begins. The formulary publishes.

And in year three, primary care and mental health become free at the point of service for every single American, regardless of what covers them.

That is the cheapest, most visible, most popular thing in this plan, and it lands early on purpose. You have to feel it before anyone asks you to trust it. Every successful social insurance program in American history delivered a benefit before it demanded a sacrifice.

Years four and five, we cover everyone else, in two age bands. Thirty five to fifty four, then nineteen to thirty four. The employer contribution replaces employer premiums. The individual contribution replaces worker premiums. The tax break disappears. Out of pocket spending ends. Universal coverage is complete at the end of year five.

Years six through eight, long term care phases in, home and community based services first, financed separately and scored separately, so that slowing it down never destabilizes the core.

Years nine and ten, independent evaluation and a statutory reauthorization vote on payment rates, the formulary process, and capacity investment.

We pay the people this plan displaces

Easy to understand summary of this section: About 1.8 million people lose their jobs under this plan, roughly 800,000 in insurance and a million more in billing offices and hospitals. These are not spreadsheet abstractions. Ninety-two percent of the provider-side jobs belong to women, most of those workers never finished a four-year degree, and nearly 300,000 are over sixty. Their jobs are the waste. They are not. So the bill funds three years of full wage replacement, pension protection, and free retraining, at $250 to $350 billion over ten years, written into the statute where nobody can quietly strike it.

Researchers at the University of Massachusetts estimated roughly eight hundred thousand jobs in the insurance industry and slightly more than one million in providers’ offices, clinics, and hospitals will be displaced with this kind of plan. About one point eight million people. Dr. David Himmelstein puts the number somewhere in the range of two million.

These are not abstractions on a spreadsheet. Median wages run near fifty four thousand four hundred dollars in health insurance and roughly thirty four thousand five hundred to thirty nine thousand four hundred in health care administration. About ninety two percent of the provider side administrative jobs belong to women. More than a third belong to people of color. Over eighty percent of those workers hold less than a four year degree. Nearly three hundred thousand of them are sixty years old or older, an age at which starting over turns brutal.

Their jobs are the waste. They are not.

So the Action Jackson BOND Health Care bill funds a Health Workforce Transition Program. Full wage replacement for up to three years. Pension protection. Tuition free retraining. Hiring preference in the new administration and in the expanded clinical workforce. Budget two hundred and fifty to three hundred and fifty billion dollars over ten years, sized to one point eight to two million workers, correcting my earlier undercount, and write it into the statute where nobody can quietly strike it in conference committee.

For scale, the American economy laid off more than twenty one million workers in 2018 alone. Absorbing one point eight million transitions across four years raises the national layoff rate by about two percent. Finance and insurance recorded one point seven million layoffs across a recent four year stretch, and almost nobody in the business press wrote a word about it.

The churn is manageable. Doing this to people without paying them is unacceptable. Every prior reform that treated these workers as somebody else’s problem deserved to lose.

What could still go wrong, named out loud

Easy to understand summary of this section: Here are the ways this plan can fail, said out loud. Congress has a bad record of holding the line on payments, waiting rooms could form if capacity lags, drug research takes a hit, and one payer means whoever runs it runs American medicine. Then every objection you’ll hear gets answered, from the Dutch model to Medicare Advantage to the public option. On the scariest one, concentrated power, here is the counterweight: the entity deciding today whether your daughter’s treatment is medically necessary is unelected, unaccountable, and legally bound to its shareholders, never to her. Choose your sovereign. Only one of them lets you vote.

Congress cannot hold payment rates. The Sustainable Growth Rate formula ran from 1997 to 2015, and between 2003 and 2015 Congress passed seventeen short term doc fixes overriding it, at a cumulative cost well over one hundred billion dollars, until the deferred cut reached twenty one point two percent and Congress simply repealed the formula. Any projected saving that depends on legislators absorbing provider pain carries a poor record. The insulated board is the structural answer. The insulated board is not a guarantee.

Waits. If capacity lags demand, lines form, and American tolerance for waiting sits near zero. This is the likeliest cause of failure, which is why capacity comes before coverage in the sequence.

Innovation. Single buyer pricing cuts pharmaceutical and device revenue. Public research funding substitutes imperfectly for private capital chasing returns. The magnitude is uncertain and I will not pretend otherwise.

Concentrated power. Put the health system in one payer and whoever controls that payer controls American medicine. The formulary becomes a political object. So does the definition of medically necessary care. Americans across the political spectrum have sound reason to fear this and the fear is not partisan hysteria. An insulated board, statutory benefit definitions, state level administration, published reasoning, and individual appeal rights all reduce the risk. Against a determined and unified government, none of it suffices.

Every objection you will hear, answered

They will tell you single payer is not the only road to universal coverage. In that ten country comparison, Australia, the Netherlands, and the United Kingdom took the top three spots, and the Netherlands runs regulated competition among private insurers with mandated individual purchase and risk equalization. Switzerland and Germany run variants. The objection is serious and it deserves a serious answer.

The Dutch system works because Dutch regulators dictate terms to insurers. American regulators have never been able to do that. We have attempted incremental multi payer regulation in this country for fifty years and produced the most expensive system on earth, the worst outcomes among wealthy peers, roughly one hundred million adults carrying health care debt, and administrative costs running two to four times those of every comparable nation. The concentration of the insurance and hospital industries, and the political power that concentration buys, is precisely why regulated competition has not worked here. And notice what this plan is. Not the British model. The Australian one. Public payer, private delivery, supplementary coverage permitted. The objection’s own first place finisher is the model on this table.

I concede the crux. Whether American government has the capacity to sustain regulated multi payer competition is a contested empirical question, and where you land on it depends more on your estimate of American administrative capability than on any reading of health economics.

They will tell you government price setting misallocates capital and suppresses supply, showing up as shortages. Partly true, which is why capacity comes first in the sequence and why this plan rejects Medicare rate payment. Now notice the assumption buried inside the objection. It assumes current American prices are set by markets. They are not. They are set in bilateral negotiations between concentrated hospital systems and concentrated insurers, in which you have no seat and no information. Maryland’s rate commission did not replace a market. Maryland’s rate commission replaced a cartel, and it produced one point four percent hospital spending growth and a forty three point three percent drop in hospital acquired conditions.

They will tell you the savings are one time, that cost growth resumes, because the real drivers, technology and an aging population, go untouched. Largely correct, and this plan does not pretend otherwise. Score only half the administrative gap, roughly three hundred billion dollars a year, and you have more than covered the cost of insuring every uninsured American in the country. Permanent cost control demands a growth constraint. That is the job of a global budget with an automatic corrective trigger, so that when spending growth exceeds the economy’s growth plus one percentage point, the board is required by statute to act. Taiwan supplies the caution. Taiwan adopted global budgets in 2002 precisely because fee for service inside a single payer system still produced rapid growth.

They will tell you Medicare Advantage proves Americans prefer managed private plans. Americans prefer the benefits, and the benefits are subsidized by you. Federal law lets those plans keep up to fifteen percent of their revenue for administration and profit, and analysis of their medical loss ratios put administration plus profit at about seventeen percent in 2020. Half of all Medicare Advantage enrollees live in counties where the government sets the payment benchmark seven and a half to fifteen percent above what traditional Medicare spends. The commission that advises Congress on Medicare found the plans collected three point six percent more in 2020 simply by recording more diagnoses on their enrollees.

That spread is a toll. Americans like extra benefits and no cost sharing at the counter, which is exactly what the core benefit hands them directly, with nobody collecting at the booth.

They will tell you a public option captures most of the benefit with far less disruption, and that it polls vastly better. The polling point is true and I will not wave it away. In a January 2020 survey, sixty five percent of Americans supported a public option, including forty two percent of Republicans, and most Republicans opposed Medicare for All. Support for Medicare for All has ranged from roughly fifty one to fifty nine percent depending on the year and the wording, and it collapses the moment respondents hear arguments about tax increases or treatment delays. State the tradeoff plainly and the public splits nearly down the middle.

Then there is the landmine. About sixty seven percent of the people who support Medicare for All believe they would keep their current insurance. They would not.

On the merits, a public option preserves the multi payer billing apparatus, which is where the administrative savings sit. It captures the coverage gain and forfeits most of the savings, which means financing it with brand new money in place of money already flowing, which makes it more expensive to the Treasury for every person covered.

On the politics, this rollout is built so that years two and three look like a public option to a skeptical voter and deliver benefits before demanding sacrifice. Stop the whole thing right there and the country has still cut premiums for the commercial pool, capped hospital prices, and made primary care and mental health free for everybody. A plan that fails safely in year three beats a plan that fails catastrophically in year one. Vermont failed in year one.

They will tell you that federal control of the health system hands a power to your political opponents that no faction should hold. This is the objection I find hardest to dismiss and I am not going to pretend I have fully answered it. The mitigations are structural. A board insulated like the Federal Reserve. Benefit definitions written into statute so narrowing them requires an act of Congress. State level administration on the Canadian provincial model. Published reasoning for every coverage decision. Individual appeal rights. Against a determined and unified government, none of that suffices, and I say so.

Here is the counterweight. The system you have right now carries the identical risk. It has simply privatized it. The entity deciding today whether your daughter’s treatment is medically necessary is unelected, unaccountable, unappealable in practice, and legally bound to its shareholders, and never to her.

Choose your sovereign. Both answers are uncomfortable. Only one of them lets you vote.

Four things you can say to anyone

1/ You already pay for this. Your employer put twenty thousand one hundred and forty three dollars into health insurance last year. The money came out of your wages. You have simply never seen it.

2/ Your doctor stays your doctor. Nothing gets nationalized. No networks. No prior authorization. No surprise bills. No coverage denials. Want more, buy more.

3/ Your job stops owning your health. Quit if you want. Start the business you have been sketching on napkins for six years. Take the risk. Job lock is a tax on American courage that no other developed country imposes on its people.

4/ Nobody in America goes broke because they got sick. Not one person. Ever again.

Now do something with this

That last sentence is the whole thing. No competing proposal in American politics can make that promise and mean it.

You are going to hear that this plan is too expensive. Now you know the country’s own budget office found national spending stays flat or falls. You are going to hear that you will lose your doctor. Now you know your doctor stays your doctor, in a privately owned practice, with less paperwork and more pay. You are going to hear that nothing this big has ever been done. Now you know Taiwan covered ninety two percent of its people in twelve months, and Maryland has been doing the hard part for over a decade, in America, under American law, with American hospitals.

They are counting on you not knowing any of this. They have counted on it for fifty years, and for fifty years it has worked, and the bill for that arrives every month in your mailbox with your name printed on the front.

So here is what I am asking you to do today.

Send this to the person in your life who walked out of a pharmacy without the medicine. They are not hard to find. Twenty seven percent of American adults left a prescription unfilled last year because of the price, and forty three percent changed how they took their medicine to make the bottle last.

Call your representative and your two senators, and ask them one question. Do you support publishing the household contribution schedule inside the bill, in dollars, before any vote. Their answer tells you whether they are serious or whether they are performing.

Then ask everyone running for office in your district and your state the same question I would ask a witness on cross examination. If this plan is wrong, show me the number that is wrong. Not the slogan. The number.

Nobody in America should go broke because they got sick. Not your parents. Not your kids. Not you.

We already have the money. We have had it the whole time. The only thing standing between you and that card in your wallet is a Congress that has never once been made to feel afraid of what happens when you find out the truth.

Now you know the truth.

Go make them feel it.

Mitch Jackson, Esq.

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1. The Five Strongest Objections to This Plan, Answered

Every argument in the article above rests on five load bearing claims. Below are the toughest counterarguments to each one, stated the way an intelligent opponent would state them, followed by my answer. I am not going to soften the objections. You deserve to see them at full strength before you decide.

Objection One. Free care means unlimited demand.

The claim I make is that copays and deductibles should be eliminated entirely. The counterargument is that free care invites overuse. Critics point to the same RAND experiment I cite and note that families facing ninety five percent coinsurance spent about thirty percent less on health care than families with free care. Remove the price and demand climbs. Emergency rooms fill with people who could have waited. The federal budget office itself warned that supply under a single payer system would fail to meet all of the new demand, thereby constraining the rise in national health spending. Free at the counter turns into a line down the hallway.

The answer. Read the rest of that RAND finding. Cost sharing produced no adverse effect on the health of participants in general, with clear exceptions. Free care delivered measurable improvement in blood pressure control, dental health, vision, and selected serious symptoms, and those gains landed on low income people in poor health, who under cost sharing went without care they needed. The reason sits in the mechanism. Cost sharing cut highly effective care and less effective care in roughly equal proportions, which means the copay never sorted the necessary visit from the unnecessary one.

The deductible study forty years later confirmed it. When one large firm moved every employee from a free plan to a high deductible plan, company spending fell roughly twelve to fourteen percent, and the researchers found no evidence of price shopping. The sickest quarter of those workers cut their spending by eighteen to twenty two percent, even though the structure of their plan left the true price of their next dollar of care close to zero for most of the year. They cut anyway. The deductible frightened them before they ever reached it.

Demand gets managed on the supply side of the system, where doctors work, and not at the counter, where frightened people make bad calls about their own chests. That is the job of hospital global budgets, of capacity investment, and of the national fee schedule. It is also why this plan begins capacity investment in year one and completes universal coverage in year five. The gap between those two dates exists precisely because the budget office issued that warning and I read it.

Now look at the American record. This country runs substantial cost sharing across nearly every plan and spends fourteen thousand seven hundred and seventy five dollars per person on health care, almost five thousand dollars more per person than Switzerland, the next highest spending nation on earth. Roughly twenty seven million Americans, about eight percent of us, carry no coverage at all. Decades of copays and deductibles have not held down what this country spends. They have held down what sick people and poor people receive.

Objection Two. Calling it free is a shell game, and the taxes will be enormous.

The claim I make is that the money already exists and simply changes its name on the check. The counterargument is that this dodge hides a tax increase of historic size. Federal spending rises by one and a half to three trillion dollars. Somebody writes that check. Vermont ran the numbers honestly and needed an eleven and a half percent payroll tax. Worse, the projected national savings depend on paying doctors and hospitals less than they collect today, and Congress has never held the line on provider payments. Between 2003 and 2015 Congress enacted seventeen separate short term overrides of its own Medicare payment formula before giving up and repealing it. The savings evaporate. The taxes remain.

The answer. The taxes rise. I said so in the article, I said so in the bill, and I put the rate schedule in the statute with a public household calculator so you can look up your own number before any member of Congress casts a vote. That transparency is the entire point. Vermont did not fail at arithmetic. The three major analyses of the Vermont plan, from Harvard, from the University of Massachusetts, and from the state itself, each concluded the state would spend less overall and that costs would fall for the roughly ninety percent of Vermont families earning under one hundred and fifty thousand dollars. Vermont failed at sequence, because the promise arrived three years ahead of the price tag and the governor had nothing to show anyone.

The average employer already sends twenty thousand one hundred and forty three dollars a year into a family health plan, and economists across the political spectrum agree that money comes out of wages. The average worker pays six thousand eight hundred and fifty dollars on top of it. A premium is a tax with no vote attached to it. Trading a larger invisible payment for a smaller visible one is a raise.

On the payment formula, the objection is correct and I refuse to wave it away. It is why this plan places rate decisions inside an independent board with staggered fourteen year terms and a budget beyond the reach of annual appropriations, built the way the Federal Reserve is built. It is also why this plan declines to pay Medicare rates in the first place. The savings here come from administration and from brand name drug prices, both of which are structural, and the budget office found that even its higher payment scenarios produce national savings.

Objection Three. One payer means a bureaucrat between you and your doctor.

The claim I make is that public financing leaves private medicine untouched and your doctor stays your doctor. The counterargument is that whoever controls the single payer controls American medicine. The national formulary becomes a political object. The definition of medically necessary care becomes a campaign issue. Hand that power to a government you trust today and you have handed it to a government you fear in four years.

The answer. This is the objection I find hardest to dismiss and I am not going to pretend I have answered it completely. The mitigations are structural. Benefit definitions written into statute so that narrowing them requires an act of Congress. State level administration on the Canadian provincial model. Published reasoning behind every coverage decision. Individual appeal rights. Supplementary private coverage stays legal, so anyone who wants more can buy more. Against a determined and unified government, none of that suffices, and I say so plainly.

Here is what makes the objection misplaced as an argument for keeping what we have. Look at how the private version of this power operates today. Insurers on the federal marketplace denied nineteen percent of in-network claims in 2024, roughly eighty five million denials in a single year. Consumers appealed fewer than one percent of them. Of the appeals that were filed, insurers upheld their own original decision sixty six percent of the time. The right to appeal exists on paper and almost nobody uses it, and most of the people who do use it lose.

The entity making those calls about your family is unelected. You did not choose it, your employer did. It answers to shareholders and it will never answer to you. You already live under the sovereign described in this objection. The sovereign is simply private, and you have never once had the chance to vote against it.

Objection Four. This plan bankrupts hospitals and cuts doctors’ pay.

The claim I make is that providers survive and improve under all payer rate setting. The counterargument is stronger than most people realize, and the numbers deserve to be stated at full force. In 2022, employers and private insurers paid hospitals an average of two hundred and fifty four percent of what Medicare would have paid for the same services at the same facilities. In some states the figure ran above three hundred percent. Move every patient to Medicare rates and you strip most of the revenue that keeps rural hospitals, safety net hospitals, and academic medical centers open. Maryland gets held up as proof this works, and one study of Maryland found nine hundred and seventy five million dollars in Medicare savings alongside no overall savings for commercial plan members.

The answer. This plan does not pay Medicare rates and never proposed to. It funds a rate between Medicare and commercial and recovers the difference from administration and from brand name drugs, where American gross prices run more than four times what other wealthy nations pay for the same medicine, and still more than three times after accounting for the rebates American manufacturers pay back. The budget office modeled higher payment scenarios and found they still produce national savings, because the waste is that deep.

On Maryland, the objection is accurate and the people who discovered the problem already solved it. Maryland moved to the Total Cost of Care Model in 2019, the first federal model holding an entire state accountable for the full cost of care for Medicare beneficiaries, and that model was on course to save Medicare over a billion dollars by the end of 2023. This plan adopts the successor design.

On doctors, the arithmetic runs the other direction from the objection. Analysts writing in Health Affairs examined the budget office data and found clinician payments rising under all five single payer scenarios modeled. Those analysts disclose that they are themselves physicians, and to their credit they wrote that such a windfall may be excessive for some providers. Take the finding along with the caveat. The direction is what matters, and the direction is up.

The reason sits in the overhead. Mean overhead runs about fifty six percent of revenue in American physician practices against twenty four point seven percent reported by Canadian physicians, and the researchers note their figures include items unrelated to billing, such as malpractice insurance, which costs more here for its own reasons. Even discounting for that, your doctor spends a fortune fighting insurance companies. Take that fight away and the money goes back into the practice. Rural hospitals get a guaranteed revenue floor tied to the population they serve, which lets a small hospital stop chasing volume it does not have and start serving the county in front of it.

Objection Five. Ten years spans three presidents, and it costs 1.8 million jobs.

The claim I make is that a phased ten year rollout works. The counterargument is that no American reform survives that long. The next administration repeals it in year four, the way every landmark law faces a repeal campaign the moment power changes hands. And the savings that make the plan work come from eliminating roughly one point eight million administrative jobs, including about one million in providers’ offices, clinics, and hospitals, where ninety two percent of those workers are women, more than a third are people of color, and over eighty percent hold less than a four year degree.

The answer. The sequence is built to fail safely. Year two covers children and adults fifty five to sixty four, which pulls the sickest cohort out of the commercial risk pool. That removal should lower private premiums for every employer still in that pool, before anyone is asked to give up a thing. Year three caps hospital prices nationally and makes primary care and mental health free for every American regardless of what covers them. Stop the entire program right there, in year three, and the country has still cut premiums, capped prices, and delivered free primary care.

Every phase stands on its own. Every phase delivers something a voter can feel in the same year it costs them something. That is the design, and the design exists because a program people can feel is a program people defend.

On the workers, the objection is not a reason to preserve the waste. It is a reason to pay the people trapped inside it. Their jobs are the waste. They are not. This plan writes a Health Workforce Transition Program into the statute at two hundred and fifty to three hundred and fifty billion dollars over ten years, sized to every affected worker, with full wage replacement for up to three years, protected pensions, tuition free retraining, and hiring preference across the expanded clinical workforce. For scale, the American economy laid off more than twenty one million workers in 2018 alone, and none of them got anything close to this. This bill funds every displaced worker, by name, in writing, before a single office closes. Reform that treats these workers as somebody else’s problem deserves to lose, and this one refuses to.