Among high-income democracies, the United States is the only country that has not made universal coverage the policy floor. We pay roughly twice what peer nations pay per person for healthcare, and we live shorter lives than the citizens of every peer nation that pays half. The proposals below attack the structural reasons for that gap from six directions at once: financing, drug costs, workforce supply, payment incentives, mental health, and the long-term care that comes with aging. The moral case for not making people choose between insulin and rent stands on its own.
STATE :: HEALTHCARE SPEND VS. OUTCOMES
The chart below tells the whole story. Every dot is a country: where it
sits on the horizontal axis is what it spends per person on healthcare
each year; where it sits on the vertical axis is how long its people
live. The six proposals on this page attack the structural reasons the
United States dot sits where it does: alone, far to the right and
visibly below every peer.
These proposals would begin no earlier than January 2029, after the
next presidential term starts. Each depends on the laws, funding,
and preparation it requires.
01▸Universal Coverage via Medicare Buy-In
Mechanism: We propose lifelong coverage through an expanded and improved Medicare system, including medical, dental, vision and hearing care. You can keep work insurance without a second public-plan premium. Switching is voluntary.
Public premiums are zero through 200% of the poverty guideline. The rate then rises linearly to 6% at 500% of the guideline, and stays there above that point. The rate applies to household income. Premiums cannot exceed the plan's full price. This caps premiums, not all medical costs or taxes.
Eligible uninsured people with no premium enroll by default, with an easy opt-out. A nonzero premium needs explicit agreement before debt begins. Eligible people who remain uninsured keep full publicly funded coverage even if they never respond. Silence does not create a bill or a coverage deadline.
All employers must contribute based on payroll. Their spending on qualifying work coverage can meet that duty; any gap goes to the public plan. Worker deductions earn no credit. An employer's missed payment must not end your public coverage or become your debt.
All qualified providers offering covered care must accept the public plan. No cash-only opt-outs or extra patient bills. Covered care has no deductible, copays or coinsurance. The plan must help you get care on time. Premiums remain separate.
Mechanism: Your prescriptions cost what they cost in Canada, not three times more. Insulin proved the point: when Washington capped it at $35 a month for seniors, drugmakers cut the list prices they had defended for decades. List prices fell because they were a choice all along. Getting every patient the dose remains unfinished work, which is exactly why the fix has to reach prices system-wide instead of one drug at a time.
This proposal makes that choice for every drug Medicare buys. Speed up and widen Medicare's new power to negotiate prices, and tie the ceiling to what peer countries pay for the same drug. Medicare buys medicine for tens of millions of people at once. That much buying power is how every other rich country gets a fair price, and it flows straight to your pharmacy counter and the federal budget.
The result: no more rationing pills to make the bottle last, no more skipping refills over the bill, and no more American families paying for the world's research alone.
03▸Healthcare Workforce Pipeline
Mechanism: You can see a doctor within a week, not wait three months. Three fixes. Train more doctors: Medicare's 1997 cap still limits training. The 2021 law added 1,000 slots in phases; the 2023 law added 200 more from fiscal 2026. We raise the cap further. Use the professionals we already have: let nurse practitioners, physician assistants, and midwives do the full job they trained for. And speed up visas for doctors trained abroad who want to practice here.
Training limits are one part of a shortage shaped by aging, where doctors practice, and the fields they choose.
04▸Outcomes-Based Payment Reform
Mechanism: Your hospital gets paid for making you healthy, not for running more tests. Today Medicare and Medicaid mostly pay per procedure: more scans, more bills, whether or not you get better. We shift that money to results: one price for a whole course of treatment, and budgets that rise or fall with how healthy patients actually stay.
Doctors and nurses have asked for this for decades. They did not go into medicine to chase billing codes, and the current system punishes the ones who order fewer, better-chosen treatments. Change what we pay for, and we change what we get.
05▸Mental Health Care That Answers
Mechanism: When your mind breaks, the system should answer the way it answers a broken arm: this week, nearby, covered. Today 157 million Americans, nearly half the country, live in a federally designated mental-health shortage area, and only about half of adults with a mental illness get any treatment at all.
Four parts. Finish the clinic map: certified community behavioral health clinics take walk-ins for mental health and addiction care regardless of insurance, and Congress has scored and funded their spread twice on bipartisan votes. More than five hundred clinics operate today; the full payment model covers about twenty states, with ten more joining. Fund the rest. Make 988 answer everywhere: the crisis line now handles millions of contacts a year and answers about nine calls in ten, but in much of the country the only responder it can send is a police car. Fund mobile crisis teams so a mental-health call gets a mental-health response. Enforce the parity law: since 2008, insurers must cover mental health like physical health. The rule with teeth was finished in 2024, then paused in 2025 after an industry lawsuit. Un-pause it, and audit insurers on their own access numbers. Build the workforce: expand loan repayment for counselors who practice where the shortages are, because the country is short about a hundred thousand of them within the decade.
Untreated mental illness drains about $282 billion from the economy every year, the size of an average recession. We already pay for the broken version.
Mechanism: Getting old in this country should not mean losing everything you saved, and your daughter should not have to quit her job to keep you out of a facility. Most people want to age at home, and Medicaid's own books agree: it spends about $32,000 a year per person on home-based care versus about $45,000 in a facility. But Medicaid, which pays for most long-term care, was built facility-first. Home care is the optional extra: over 600,000 people, most of them with developmental disabilities, sit on state waiting lists for it, waiting almost three years on average. Rationing is the current policy.
Four moves flip the default. Clear the waiting lists: extra federal matching money for states that fund home-care slots until the line is gone. Pay the workers: the match comes with a wage floor, because home-care workers earn about $17 an hour, turnover runs near 75 percent, and the country needs millions more of them within the decade. Back the families: a capped tax credit, up to $5,000 a year, for out-of-pocket costs when you care for a parent or spouse at home. And make home the default: when someone qualifies for long-term care, the money follows them home unless they choose a facility.
To be clear, this is new spending that buys more care at a lower cost per person, not a program that pays for itself. What it replaces is the invisible system: 59 million Americans providing unpaid care worth about a trillion dollars a year, most of it from women who cut hours or leave work. That bill is already being paid, by families, off the books.
STATUS :: COVERAGE GAP▸ 26.7 million Americans under 65 were uninsured in 2024, a number that grew by 1.3 million in just one year. More than one in three of them skipped, delayed, or went without care or medication they knew they needed because they couldn't afford it.
◇ KFF, "Key Facts About the Uninsured Population," 2024 data (published 2025) ↗
STATUS :: PAYING FOR WASTE▸ A 2019 review estimated $760 billion to $935 billion in annual waste across six categories: care delivery, care coordination, low-value care, pricing, fraud and abuse, and administrative complexity. Overtreatment or low-value care was $75.7 to $101.2 billion of that total. The review does not attribute all waste to fee-for-service or show that payment reform can recover the full amount.
◇ JAMA, Shrank, Rogstad & Parekh, "Waste in the US Health Care System: Estimated Costs and Potential for Savings," October 2019 ↗
METHODOLOGY :: OECDHEALTHCARESCATTER
▸ HOW THE SCATTER IS BUILT
Each country is one dot positioned by its healthcare spending per
capita (USD PPP) on the horizontal axis and its life expectancy
at birth on the vertical axis. The faint trend line is an
ordinary-least-squares regression through the OECD distribution.
The dashed median crosshairs mark the OECD median spend and the
OECD median life expectancy; the United States sits visibly to
the right of and below those medians — highest spend, life
expectancy below the OECD typical value. Peer nations (high-
income OECD) are labeled with country codes; other OECD members
are shown as muted dots to provide regression context.
Data sourced from World Bank / WHO Global Health Expenditure
Database, which shares the same System of Health Accounts (SHA)
submission pipeline as OECD Health Statistics.
All OECD member nations with complete 2022 data for both
indicators are included.