Medicare already exists. It works. It is popular. The trick is to expand it downward and outward—first to everyone over 55, then to children, then to anyone who wants in—while simultaneously standardizing reimbursement rules across private plans. The goal is not to outlaw private insurance. It is to make it redundant.⁸
This matters because cost control does not come from price caps alone. It comes from simplicity. Every hospital administrator in America can tell you how many staff hours are burned reconciling billing codes across dozens of insurers. Eliminate that friction, and you free billions before touching a scalpel.⁹
But coverage is only the chassis. The engine is primary care—and this is where the American system quietly collapses.
We have built a country where it is easier to see a specialist than a generalist, easier to get a procedure than a conversation. That is not an accident. It is a reimbursement choice.¹⁰ If you want best-in-world outcomes, you pay for continuity, not heroics.¹¹
The post-2028 plan must do something radical by American standards and utterly mundane elsewhere: guarantee every person a primary care clinician with a capped panel size and a salaried model. No fee-for-service hamster wheel. No incentive to rush. Just time, accountability, and prevention.¹²
Countries that do this—quietly, relentlessly—catch disease earlier, spend less on catastrophic interventions, and trust their systems more. We know this because we can measure it.¹³ The resistance is not empirical. It is cultural and financial.
Which brings us to drugs—the most visible, obscene failure in the American model.
The United States subsidizes global pharmaceutical innovation and then pretends this is an act of generosity rather than leverage. We pay the highest prices in the world for medications whose research we often helped fund, then forbid our own government from negotiating aggressively on our behalf.¹⁴ This is not market capitalism. It is self-imposed extortion.¹⁵
A best-in-world system after 2028 would do three things simultaneously. It would expand federal price negotiation to all high-volume drugs. It would enforce international reference pricing. And it would break the patent abuse pipeline that allows minor reformulations to reset monopolies indefinitely.¹⁶
None of this requires new science. It requires spine.
The same applies to hospitals.
The quiet secret of American health care costs is that they are driven less by wages or technology than by consolidation. Over the past two decades, hospital systems have swallowed competitors, negotiated higher prices, and justified it all in the language of “efficiency.” The result has been fewer choices, higher bills, and no measurable improvement in outcomes.¹⁷
A serious reform agenda uses antitrust law as health policy. It blocks further consolidation. It forces price transparency that actually means something. And it ties nonprofit hospital status to measurable community benefit, not branding exercises.¹⁸
If a hospital receives tax exemptions, it should prove—annually—that it is reducing uncompensated care, expanding access,