Introduction

It is a uniquely American barbarism that in the wealthiest nation in human history, your ability to survive a cancer diagnosis depends entirely on who signs your paycheck. We have accepted a status quo where healthcare is neither a right of citizenship nor a true market commodity, but a feudal privilege granted by corporate employers. This system acts as a tax on the sick and a cage for the working class, forcing millions to cling to dead-end and unfulfilling jobs they hate in order to fill their life saving prescriptions each month. It stifles the artist, the entrepreneur, and the gig worker, punishing anyone who dares to step outside the safety of a corporate HR department.

The numbers tell a stark story. In 2025, the average American family with employer-sponsored coverage pays $26,993 annually in premiums - more than the cost of a new Toyota Corolla.¹ As Kaiser Family Foundation President Drew Altman observed, "Employers are shelling out the equivalent of buying an economy car for every worker every year to pay for family coverage."² This represents three consecutive years of 6% or higher increases - the first time we've seen such sustained acceleration in two decades. Yet despite spending more per capita on healthcare than any nation on earth - $14,885 compared to the $7,371 average for wealthy countries- Americans have lower life expectancy, higher infant mortality, and worse health outcomes than our peers.3

But while the moral outrage driving the "Medicare for All" movement is entirely justified, the standard diagnosis is wrong. The American healthcare disaster is not the result of a "free market run amok." It is the toxic byproduct of a bureaucratic accident in a 1942 wage control law and a tax loophole that accidentally incentivized corporations to become our welfare state. To achieve the progressive dream of universal security, we cannot simply subsidize this broken, accidental architecture. We must finish the work of the New Deal by doing the one thing the current system refuses to do: sever the link between our labor and our lives, and return the power of choice to the worker.

The Original Sin and "Corporate Feudalism” of American Healthcare Policy

To understand why our healthcare system is so uniquely dysfunctional, we must look back to the moment it was broken: not by a greedy insurance CEO, but by a well-intentioned government bureaucrat in the midst of World War II.

In 1942, the United States faced a crisis. With millions of working-age men deployed overseas and war production ramping up, labor was scarce. The Roosevelt administration, terrified that desperate factories would bid wages up and trigger hyperinflation, passed the Stabilization Act of 1942.4 This law imposed a strict freeze on wages. It was a massive government intervention designed to pause market forces for the good of the war effort.

But economic forces, like water, always find the cracks.

Desperate to attract workers but legally forbidden from offering higher pay, corporations turned to the War Labor Board for a loophole. The Board, in a series of rulings between 1943 and 1945, determined that while cash wages were frozen, "fringe benefits" like health insurance were not.5 Almost overnight, companies like General Motors and U.S. Steel began offering generous health plans as a way to bypass the wage freeze.

The War Labor Board's logic was straightforward but shortsighted. They reasoned that health benefits didn't constitute "wages" in the traditional sense, rather they were in-kind transfers that wouldn't directly fuel inflation. Board members, who were focused on the immediate crisis of war production, gave little thought to the long-term consequences of this carve-out. Minutes from Board meetings reveal that they viewed health insurance as a minor fringe issue, not the foundation of a future welfare state.6

This might have been a temporary wartime quirk if not for the Internal Revenue Service (IRS). In 1943, and later codified in the Internal Revenue Code of 1954, the IRS ruled that these new benefits would be tax-deductible for the employer and tax-exempt for the employee.7 This wasn't a carefully considered policy decision, it was an administrative ruling that happened almost by accident, driven by the need to clarify the tax treatment of this new form of compensation.

The 1954 codification is particularly revealing. President Eisenhower, generally skeptical of expansive government, signed off on this tax preference as part of a broader tax code revision. Why? Because by 1954, millions of Americans already had employer-based coverage, and unions had made health benefits a central part of collective bargaining. The tax exclusion had created a constituency that would fight to preserve it. Walter Reuther of the United Auto Workers (UAW) declared employer health benefits "a new frontier in the American social contract."8 What began as a wartime workaround had become, in just over a decade, politically untouchable.

The result was catastrophic for the long-term health of the American worker. The government had effectively created a massive tax shelter that only worked if you handed control of your healthcare over to your employer.

The Three-Party Problem

This 1942 accident created what economists call "third-party payment" - a system where the person receiving care, the person providing care, and the person paying for care are three different entities with fundamentally misaligned incentives.

Buying things like groceries or gasoline is simple. You see the price, judge the quality, pay for it yourself, and take it home. Because it’s your money, you care about getting your money’s worth. And because the seller wants your business, they have to offer something worth buying.

Under the employer-based insurance system, medical care became radically different:

• The patient receives care but doesn't pay for it directly

• The doctor or hospital provides care but bills a third party

• The insurance company (or government program) pays for care but doesn't receive it

This setup undermines the basic signals that make markets work and keep consumers focused on value. If you’re spending someone else’s money on someone else’s care, there’s little reason to watch costs closely or to scrutinize quality in the same way.

The tax exemption made this problem worse in two distinct ways:

First, it creates a massive subsidy - but only if you accept employer control. If a boss gives you $100 in cash to buy your own healthcare plan, the government will tax it. If they bought the plan for you, it was tax-free. This massive subsidy favored the wealthy and the corporately employed, while leaving the poor, the gig worker, and the entrepreneur to pay full price with after-tax dollars. According to the Congressional Budget Office (CBO), this tax exclusion now costs the federal government over $280 billion annually- making it one of the largest "spending" programs in the federal budget, though it never appears in appropriations bills.9

Second, it incentivizes over-consumption of medical care. Because employer-provided healthcare comes from pre-tax dollars while other forms of compensation come from after-tax dollars, employees have a stronger incentive to take more of their total compensation as healthcare benefits than they would if all compensation were treated equally. This leads to "gold-plated" insurance plans that cover every possible service with low or no copayments - further disconnecting patients from the actual cost of care.

Redefining Insurance: From Catastrophe to Routine

This system also fundamentally changed what we mean by "insurance." Traditionally, we insure against catastrophic risks: we insure our houses against fire, not against the cost of having to cut the lawn. We insure our cars against major liability or damage, not against having to pay for gasoline. Insurance is meant to protect against unlikely but devastating financial losses.

Yet in American medicine, it has become common to use "insurance" to pay for routine, predictable expenses: annual checkups, prescription refills, even minor ailments. This isn't really insurance in the traditional sense, rather it's prepaid healthcare managed through a bureaucratic intermediary. The result is that "without medical insurance" and "without access to medical care" have come to be treated as nearly synonymous, even though they describe completely different concepts.

Moreover, states and the federal government have increasingly mandated the specific coverage that insurance must provide, down to minute details. The effect has been to raise the cost of insurance dramatically and to limit the options available to individuals. Many, if not most, of the "medically uninsured" are people who for one reason or another do not have access to employer-provided medical care and are unable or unwilling to pay for the only kinds of insurance contracts available to them.

The Golden Handcuffs

This accidental architecture created the "job lock" we suffer from today. Healthcare became a tool of labor discipline. A worker who wants to strike out on their own, unionize, or simply leave a toxic workplace has to weigh their freedom against the risk of losing coverage for their child's asthma. Economists have documented this phenomenon extensively: research consistently shows that workers with employer-sponsored health insurance are 20-40% less likely to transition to self-employment, even when controlling for risk tolerance and entrepreneurial aptitude.10

The American Exception: A Wartime Accident

It's worth exploring how other countries approached things. Britain, facing the same wartime labor shortages, responded by expanding its Emergency Medical Service into what would become the National Health Service in 1948.11 Canada maintained its employment-based insurance through the war but then deliberately built a public alternative starting in Saskatchewan in 1947. France strengthened its existing social insurance system. Only America allowed a temporary administrative ruling to calcify into the architecture of its entire healthcare system.

We are not living in anything close to a "free market" healthcare system. We are living in a statist distortion... in a system where tax code engineering and wartime wage controls accidentally conspired to tie our physical well-being to our employment status. FDR aimed to save the economy, but this specific policy inadvertently birthed a form of corporate feudalism that haunts us to this day.

When Good Intentions Meet Bad Incentives: The "Shuffle"

The moral instinct of progressives is correct: people should not suffer and die because they lack money. When we see the opioid crisis ravaging communities, the humane response is to say "let's make sure everyone can access treatment." And indeed, this is what policymakers attempted to do through the Affordable Care Act and Medicaid expansion. Addiction treatment was designated as an "essential health benefit" with no annual or lifetime limits. Access was expanded. Money flowed.

But money flowing through a broken system doesn't heal - it metastasizes. The story of what happened next is captured in "Shuffle," a documentary by filmmaker Benjamin Flaherty that won the Grand Prize at the 2025 South by Southwest Film Festival. Through intimate portraits of people seeking recovery from opioid addiction, Flaherty reveals how the very policies designed to help people access treatment instead enabled predatory operators to turn human suffering into profit streams measured in millions of dollars per patient.

The Mechanics of Exploitation

"The Shuffle" refers to a process by which clients are cycled through a rinse-and-repeat style of addiction treatment for maximum profit. It's insurance fraud that can generate up to one million dollars per year per person in insurance reimbursements. From the outside, it may look no different than legitimate treatment. But the financial incentive doesn't encourage recovery - it encourages continued treatment. That's where the profit is. In this system, recovery represents a loss of profit, a loss of business. That's a fundamental conflict of interest.

The mechanics work as follows:

Patient Recruitment: Humans as Commodities

Addicts are “recruited” to treatment centers - often lured with cash, drugs, or promises of help - because their insurance policies have value. Operators involved in this developed a hierarchy of insurance value:

1. Out-of-network plans were most valuable since they had the highest reimbursements, and the least oversight from insurers.

2. "Blue chip" state employee plans were next.

3. In-network policies paid less but still profitable.

4. Medicaid was at the bottom of the value chain.

Fabricating Coverage: The ACA Enrollment Fraud

When patients didn't have adequate insurance, operators would fabricate it. Using services like "paystubs.com," they would create fake income documentation to enroll patients in subsidized ACA plans. This wasn't an isolated problem of a few actors - it was systematic.

The data is staggering: In Florida, the epicenter of the fraud, there are five times more people enrolled in fully subsidized ACA plans (claiming income between 100-150% of the federal poverty line) than actually have that income level.12 Nationally, there are 6.4 million more enrollees claiming these income levels than are eligible. There are 15 states where enrollment exceeds eligibility by more than 200%.

As Brian Blase, former Special Assistant to the President for Economic Policy, discovered in his research: organized crime has infiltrated the ACA enrollment system because "it is just so easy to defraud the federal taxpayers." One broker involved in the fraud said, "You have to throw your morality away to do this line of work" - manipulating people into plans when they think they're getting cash gift cards.13

The Detox-Relapse Cycle: Profiting from Suffering

Once patients had valuable insurance, they would be cycled through detox facilities repeatedly. When a patient stabilized - when they were actually on the path to recovery - operators would sometimes encourage relapse, sending them back to active drug use so they could be readmitted for another profitable detox cycle.

Daily urine tests at $3,000-$5,000 per test. Genetic testing with questionable clinical justification. "Re-billing" companies like "Correctabill" that would resubmit claims with modified billing codes to maximize reimbursements. All of this happening three, four, five degrees removed from anyone actually providing care.

Unlimited Duration: The Policy that Enabled It All

The ACA's mandate that addiction treatment be an "essential health benefit" with no annual or lifetime limits meant this cycle could continue indefinitely. The insurance card became, in Blase's words, "basically a visa that you could just continue to run up bills on." There was no natural limit, no point at which the system said "enough."

The Policy Failures

The "Shuffle" wasn't the result of a few bad actors exploiting loopholes. It was the inevitable consequence of policy design that created systematic incentives for harm:

The Essential Health Benefits Mandate

By designating addiction treatment as an essential health benefit with no caps, policymakers created unlimited entitlements. The intention was compassionate - no one should be denied life-saving addiction treatment because they hit an arbitrary coverage limit. But the effect was to remove any mechanism that might limit exploitation.

The Medical Loss Ratio Perversity

Perhaps most perversely, the ACA's "Medical Loss Ratio" (MLR) requirement created systematic incentives for insurers to tolerate or even encourage high spending. Insurance companies must spend 80-85% of premium revenue on medical claims, or they must rebate money to customers.

This was designed as a consumer protection to ensure insurers don't just pocket premiums as profit. But in practice, it created a bizarre dynamic: insurers who don't spend enough on medical claims face financial penalties. As Blase's research uncovered, there are 12 million people enrolled in ACA coverage who don't use any healthcare services at all - "ghost enrollees" whose premiums insurers collect while using fraudulent claims (like from the Shuffle operations) to meet their MLR requirements.14

The fraud becomes a feature, not a bug. Insurers have perverse incentives to tolerate wasteful spending because it helps them meet regulatory requirements.

Fee-for-Service with Zero Outcome Accountability

As Flaherty observed in a discussion about his documentary: "Reimbursements aren't based on any outcome at all. That's nuts to me. Like, what other field of medicine do we have where there's no expectation of accountability?"

The answer, unfortunately, is "most of them" - American healthcare operates primarily on fee-for-service payment, where providers are paid for services rendered regardless of whether those services actually help the patient. But addiction treatment fraud makes this dysfunction particularly visible and particularly cruel.

Treatment centers are rewarded for throughput - for churning people through the system. Recovery, the actual goal, represents a loss of business. As Flaherty concludes: "I don't believe the treatment system is broken. Is it easily manipulated? Yes, but I believe the treatment system is doing exactly what it was designed to do: create profit... recovery is only a secondary concern, only a 'reasonably expected outcome.'"15

Medicaid Expansion Effects

Research by journalist Sam Quinones and others has documented that states adopting Medicaid expansion under the ACA experienced worse opioid crises in the initial years. The "Medicaid card became a vehicle to access opioids and the abuse that was there."16 Well-intentioned expansion of coverage, without addressing the underlying payment structure and oversight mechanisms, simply channeled more money into a system ripe for exploitation.

"Pay and Chase" Enforcement

Like Medicare and Medicaid before it, ACA programs operate on a "pay and chase" model - the government pays claims first, then tries to identify fraud later. The Biden administration suspended 850 brokers involved in enrollment fraud. However, the fraud continued to escalate because the underlying incentives remained unchanged.

Why? Because enforcing against fraud is expensive and difficult. Any enforcement mechanism strict enough to catch fraudsters will also impact legitimate providers, who then lobby against the restrictions. As Michael Cannon, Director of Health Policy Studies at the Cato Institute, explains: "Every dollar of wasteful spending... is a dollar of revenue to somebody. And that somebody has a lobbyist and will fight any effort to try to eliminate spending on wasteful services.”17 This is the "fraud lobby" - not necessarily organized criminals, but the entire ecosystem of providers who benefit from loose oversight.

The Human Cost

Behind the economics and policy analysis are three human beings whose stories Flaherty followed for three years: Corey, Nicole, and Daniel.

Daniel died during the filming.

His mother described how she could hear the excitement in operators' voices when they learned she had "blue chip" Kentucky state employee insurance. Her son's suffering - his desperate need for help, his struggle with addiction, his humanity - was reduced to a profit opportunity measured in billing codes and reimbursement rates.

As Cannon observed after watching the film: "I have to wonder if Nicole took treatment and recovery more seriously because it was no longer an unlimited entitlement to more money, because she thought, okay, this might be my last chance."18 When recovery is simply one more service dispensed from an unlimited insurance ATM, both providers and patients may lose sight of what actually matters: getting and staying sober, rebuilding a life, genuine recovery.

The Lesson for Healthcare Reform

The "Shuffle" demonstrates in devastating detail why the progressive impulse to "just expand coverage" is necessary but not sufficient. The impulse is morally correct certainly - people need access to treatment, to healthcare, to the services that might save their lives. But money flowing through a system with broken incentives doesn't heal. It creates new pathologies.

The combination of:

• Unlimited third-party payment (no patient cost-sharing or awareness)

• Fee-for-service reimbursement (paid for services, not outcomes)

• Weak outcome accountability (no measurement of whether treatment actually works)

• Perverse insurer incentives (MLR requirements that reward high spending)

• "Pay and chase" enforcement (fraud detected too late, if at all)

...creates a system where exploitation is not an unfortunate side effect but an inevitable result.

As Flaherty concludes: "Money can't solve the problem. Money is the problem" - or more precisely, the structure of how money flows through the system is the problem. Until we fix that structure, more money simply feeds more abuse.

This isn't an indictment of the goal - universal access - but of the design. A system that lacks price signals and outcome accountability is destined for failure. We must shift the power dynamic: patients must be vigilant consumers with the agency to choose value, rather than passive recipients in a third-party payment scheme that incentivizes volume over recovery.

The Supply-Side Stranglehold: Why More Money Won't Fix Broken Markets

The "Shuffle" revealed what happens when we pour money into a system without fixing the payment structure. But even if we solved the third-party payment problem, we'd still face another fundamental barrier: artificially imposed scarcity.

We are suffering from what policy analyst Samuel Hammond calls "Cost Disease Socialism."19 We try to subsidize the costs of healthcare (demand) while maintaining a regulatory stranglehold that prevents new doctors and hospitals from entering the market (supply). The result is a paradox: we spend more tax dollars on healthcare than any nation on earth, yet we get less care in return.

The numbers are staggering. Americans spend $8,353 per person annually on inpatient and outpatient care - more than double the $3,636 average in comparable countries. On administrative costs alone, we spend $925 per capita while peer nations spend just $245.20 To put this in perspective, Sweden spends 22 times more on long-term care than on healthcare administration; America spends roughly equal amounts on each. We're not just inefficient - we've built a system that prioritizes bureaucracy over care.

Why? Because the American healthcare market is rigged to favor scarcity over abundance through decades of regulatory capture.

The "Competitor's Veto" (Certificate of Need Laws)

In 35 states, it is literally illegal to build a new hospital or buy an MRI machine without government permission.21 These "Certificate of Need" (CON) laws allow existing hospitals to sue to block new competitors. This isn't "regulation" to keep patients safe; it is a protection racket. It allows large, corporate hospital monopolies to artificially restrict the supply of beds to keep prices high.

The history of CON laws reveals their corruption. They were passed in the 1960s and 70s with the perverse logic that "too many hospitals" would lead to wasteful overcapacity and higher costs. The federal government even mandated them as a condition of receiving Medicare and Medicaid funding. But when the federal mandate was lifted in 1987, most states kept their CON laws... not because they worked, but because incumbent hospitals had captured the regulatory process.22

Consider a recent case in Kentucky. In 2020, Dipendra Tiwari and Kishor Sapkota, Nepali immigrants in Louisville, wanted to open a home health agency to serve the city's Nepali-speaking community. They had identified a genuine need—language barriers were preventing elderly Nepali residents from accessing home care services. But they needed a Certificate of Need. A $2 billion healthcare conglomerate filed an objection to block their application. The state sided with the conglomerate and denied the license. Then the Kentucky Hospital Association - representing hospitals across the state - intervened in their subsequent lawsuit, even though most hospitals in Kentucky don't even operate home health agencies. The courts upheld Kentucky's CON law. The Supreme Court declined to hear their appeal. The home health agency was never opened.

This pattern repeats across the country. A 2020 Mercatus Center study found that CON laws reduce hospital beds per capita by 12%, increase prices by 5-8%, and have no measurable effect on quality of care.23 The only beneficiary is the incumbent monopolist.

The Incumbent's Veto: How Regulations Trap Technology

Policy analyst Robert Orr has provided crucial insights into why CON laws are particularly pernicious in modern healthcare. In his research at the Niskanen Center and in discussions on the Mercatus Center's Macro Musings podcast,24 Orr identifies what he calls the "Superior Good" problem: as healthcare technology improves - MRI machines become more advanced, surgical techniques become more specialized, diagnostic tools become more precise - these innovations become "superior goods" that everyone wants and that deliver genuinely better outcomes.

The original justification for CON laws was to prevent "wasteful duplication" of expensive equipment. The logic was that if too many hospitals bought MRI machines, they would sit idle, driving up costs. But Orr demonstrates that this reasoning is backwards. As healthcare technology improves and becomes more valuable, CON laws don't prevent waste - they create artificial scarcity that reserves superior medical technology for incumbent hospital systems. The result is effective rationing of modern healthcare advances to those lucky enough to live near hospitals that already possess state-granted monopolies.

Consider the implications: A state-of-the-art MRI machine that can detect tumors earlier and more accurately is precisely the kind of technology that should proliferate rapidly. Instead, CON laws ensure that only established hospital systems can acquire them, forcing patients to travel long distances or wait weeks for appointments. Independent imaging centers that could offer the same technology at half the price with same-day availability are blocked by competitors wielding government power.

Orr's insight reveals the fundamental perversity: CON laws operate under the assumption that less healthcare capacity is better, when the opposite is true for rapidly improving technologies. By treating advanced medical equipment as a scarce resource to be rationed rather than a superior good to be proliferated, we ensure that millions of Americans lack timely access to potentially life-saving innovations.

For the progressive, this should be an outrage: it is a government-enforced monopoly that prevents community clinics from opening in underserved neighborhoods and from acquiring the advanced technology that could improve outcomes. It is the state actively preventing competition that would lower prices and increase access.

The Guild Mentality (Scope of Practice Restrictions)

We are also facing a manufactured shortage of care providers. The American Medical Association (AMA) has successfully lobbied to prevent highly trained Nurse Practitioners (NPs) and Physician Assistants (PAs) from practicing independently, even for routine issues like strep throat or flu shots.

In 28 states, a Nurse Practitioner with a doctorate-level education and years of clinical experience cannot prescribe medication or diagnose conditions without a supervising physician signing off on their work.25 This requirement exists despite mountains of evidence showing that NPs provide equivalent care to physicians for primary care services, often with higher patient satisfaction scores.

The AMA's argument is couched in the language of safety, but the evidence tells a different story. A comprehensive 2018 RAND Corporation study compared health outcomes in states with full NP practice authority to restricted states and found no difference in patient safety, misdiagnosis rates, or adverse events. What they did find was a significant difference in access: states with full practice authority had 7% more primary care visits per capita and 15% shorter wait times for appointments.26

By legally forcing patients to see an expensive MD for every minor ailment, we have created a bottleneck that hurts the working class the most. A patient in rural Mississippi might live 50 miles from the nearest physician but 10 miles from a highly qualified Nurse Practitioner who is legally forbidden from treating them without physician oversight that doesn't exist in the area.

The median physician salary in the United States is $208,000, compared to $105,000 in Germany and $118,000 in France.27 Some of this reflects higher American training costs, but much of it reflects artificial scarcity maintained through licensing restrictions.

The same dynamic plays out with dental therapists (banned in most states despite successfully operating in dozens of countries), pharmacy technicians (restricted from administering basic vaccines in many jurisdictions), and paramedics (prevented from doing community health work outside of emergency transport).

The Residency Bottleneck

Beyond scope-of-practice restrictions, Robert Orr has documented another critical supply constraint: the artificially limited pipeline of physicians entering practice. In his groundbreaking research at the Niskanen Center,28 Orr exposes how federal policy systematically misallocates and constrains physician supply through two mechanisms:

1. The 1997 Medicare Residency Cap: The Balanced Budget Act of 1997 froze Medicare funding for residency positions at 1996 levels.29 This cap has remained essentially unchanged for nearly 30 years, despite massive population growth and increasing healthcare demands. Medicare funds roughly 140,000 residency positions annually, but the number of medical school graduates has grown substantially. In 2022 alone, approximately 3,300 U.S. medical school graduates went unmatched to residency positions30- not because they were unqualified, but because there simply weren't enough funded slots.

This creates an absurd situation: we train doctors at enormous expense (often subsidized by taxpayers through public medical schools), they graduate with the knowledge and credentials to practice, but then cannot complete the residency training required for licensure because Congress arbitrarily decided in 1997 that we had "enough" residency positions. The result is a physician shortage that is entirely self-inflicted through policy choice rather than any natural scarcity.

2. Foreign Medical Graduate Restrictions: Orr also documents how unnecessarily restrictive licensing requirements for foreign-trained physicians compound the shortage. A doctor trained at Oxford, the Karolinska Institute, or the University of Toronto must repeat years of residency training to practice in America, even though their medical education often meets or exceeds U.S. standards. This protectionist barrier serves guild interests but deprives communities of qualified physicians who could immediately begin addressing shortages.

The Association of American Medical Colleges projects a shortage of 54,000 to 139,000 physicians by 2033,31 with primary care and rural areas facing the most severe gaps. But as Orr demonstrates, this is not an inevitable crisis - it is the predictable result of policies designed to restrict supply and protect incumbent practitioners' income.

Orr's research connects directly to the broader argument: we cannot achieve sustainable universal healthcare without dramatically expanding supply. The residency cap and foreign physician barriers must be eliminated as part of any comprehensive reform. When combined with full practice authority for NPs and PAs, CON law repeal, and other supply-side reforms, we could rapidly increase healthcare capacity by 20-30%, driving down costs while improving access.

The FDA Bottleneck and Drug Importation Barriers

Finally, our refusal to recognize drugs approved by other advanced nations creates another artificial scarcity. If a life-saving drug is approved by the European Medicines Agency or Japan's Pharmaceuticals and Medical Devices Agency, the FDA forces the manufacturer to start from scratch in the U.S., adding years and billions in costs that are passed directly to the patient.

This is not a matter of American standards being higher. A 2017 analysis by MIT economists found that drugs approved by the EMA have equivalent safety profiles to FDA-approved drugs. The difference is bureaucratic redundancy, not scientific rigor.32

The human cost is real. When the EMA approved a breakthrough cystic fibrosis drug in 2012, American patients had to wait an additional 18 months for FDA approval... 18 months of deteriorating lung function for patients who had no other options. The financial cost is equally staggering: the estimated cost to bring a new drug through FDA approval now exceeds $2.6 billion,33 much of which represents duplicated clinical trials that have already been conducted in other advanced economies.

Worse, the FDA actively prevents Americans from importing cheaper versions of the exact same drugs from Canadian or European pharmacies. A vial of insulin that costs $300 in the United States costs $30 in Canada - same manufacturer, same formulation, same drug. But it is illegal for an American to buy it

across the border in any systematic way. This is not safety regulation; it is protectionism for pharmaceutical companies.

If we implement Medicare for All on top of this restrictive foundation, we won't get "Universal Healthcare." We will get Universal Waiting Lists and exploding deficits. True social democracy requires abundance. To lower prices, we must break the monopolies of the hospital chains and the medical guilds, unleashing a flood of new supply.

The Job Lock Crisis: How Healthcare Became an Invisible Cage

Before we can design a solution, we must fully understand one of the most pernicious and underappreciated consequences of the 1942 accident: the transformation of healthcare coverage into an invisible cage that traps American workers and stifles economic dynamism.

The data is unambiguous. Even after controlling for risk tolerance, savings, and entrepreneurial aptitude, workers with employer-sponsored health insurance are significantly less likely to transition to self-employment compared to workers with spousal coverage or other insurance sources.34 This isn't a small effect. It represents millions of Americans who would otherwise start businesses, pursue new careers, or take calculated risks, but remain locked in their current jobs specifically because of health insurance.

The mechanism is straightforward but brutal. A talented software engineer at Google dreams of building her own startup but knows that leaving means losing coverage for her daughter's asthma medication. A factory worker wants to retrain for a growing industry but can't afford to be uninsured during the transition. An artist could support himself through freelance work but stays in an office job he hates because his wife has diabetes. These are not hypothetical scenarios. They represent the daily calculus of millions of Americans whose economic choices are constrained not by market forces but by the accidental architecture of 1942.

The evidence extends beyond self-employment. Research shows that self-employment rates surge dramatically when workers turn 65 and qualify for Medicare, revealing the suppressed entrepreneurial activity that job lock creates.35 One study found that the expansion of dependent coverage under the ACA (allowing children to stay on parents' plans until age 26) increased self-employment among young adults by 19-23%, particularly among those with health conditions.36 The implication is clear: when healthcare is decoupled from employment, entrepreneurship flourishes.

The spousal insurance effect provides further confirmation. Workers whose spouses have employer coverage are significantly more likely to start businesses, change careers, or negotiate for better working conditions.37 A natural experiment from the Tax Reform Act of 1986, which made health insurance more accessible to the self-employed, increased self-employment among single women by 74% and among married women without spousal coverage by 69%.38 Healthcare portability doesn't just reduce anxiety, it unleashes economic activity.

The Kauffman Foundation, analyzing these dynamics, estimates that comprehensive healthcare reform ending job lock could increase new business formation by 15-25%.39 That represents approximately 25,000 additional businesses created annually - 25,000 innovations that never happen, 25,000 jobs that are never created, 25,000 entrepreneurs who remain trapped in corporate cubicles because they can't risk losing health coverage.

The macroeconomic costs extend beyond foregone startups. Job lock reduces overall labor market efficiency by preventing workers from moving to higher-productivity employment. When workers can't switch jobs without risking healthcare, they stay in positions that are poor matches for their skills, at companies with declining prospects, in industries that are contracting. This friction reduces productivity growth and wage growth across the entire economy. Some estimates suggest job lock reduces GDP growth by 0.1-0.2 percentage points annually,40 a seemingly small impact, but when compounded over decades the impact is enormous.

Labor relations are also distorted. Workers at non-union employers are often terrified to organize because they fear losing health benefits during strikes or lockouts. With portable coverage, that leverage disappears. Union negotiations could focus on wages and working conditions rather than desperately defending existing health plans against employer cost-cutting. The balance of power between labor and capital shifts toward workers when healthcare isn't a weapon employers can wield.

Small businesses face a particularly cruel version of this dynamic. They pay 20% more per employee for equivalent health insurance compared to large corporations, putting them at a severe competitive disadvantage in recruiting talent.41 Many simply don't offer coverage at all, making it nearly impossible to attract workers away from larger employers. The current system effectively subsidizes corporate consolidation and penalizes entrepreneurship and small business creation.

The 1942 accident didn't just create an inefficient healthcare system - it created an invisible tax on economic dynamism, a suppression of human potential, and a transfer of power from workers to employers. Before we can build a better system, we must recognize the full scope of what job lock

costs us: not just in healthcare spending, but in lost innovation, reduced productivity, and constrained human freedom.

Beyond Ideology: The Shared Diagnosis of a Failed System

At this point in our analysis, we've established three fundamental problems with the American healthcare system:

1. The 1942 accident created employer-based "corporate feudalism" through third-party payment.

2. Well-intentioned attempts to expand coverage (like the ACA) enabled systematic exploitation when grafted onto this broken structure.

3. Supply-side regulatory capture creates artificial scarcity that drives up costs.

Progressives tend to diagnose these as failures of "free market healthcare." But here's where the analysis gets interesting: free market economists identified exactly the same problems, from a completely different starting point.

Milton Friedman's Diagnosis

In 2001, Nobel Prize-winning economist Milton Friedman - whose free-market philosophy most progressives instinctively reject - published an essay called "How to Cure Healthcare." His diagnosis is worth reading carefully, because it describes precisely the dynamics we've documented in the "Shuffle" and in job lock:

"Two simple observations are key to explaining both the high level of spending on medical care and the dissatisfaction with that spending. The first is that most payments to physicians or hospitals or other caregivers for medical care are made not by the patient but by a third party—an insurance company or employer or governmental body. The second is that nobody spends somebody else's money as wisely or as frugally as he spends his own."42

Friedman wasn't making an ideological argument about the virtues of markets. He was describing observed reality: when the person receiving care, the person providing care, and the person paying for care are three different entities, the normal feedback mechanisms that create value in transactions break down.

He continues:

"The tax exemption of employer-provided medical care has two different effects, both of which raise health costs. First, it leads employees to rely on their employer, rather than themselves, to make arrangements for medical care. Yet employees are likely to do a better job of monitoring medical care providers—because it is in their own interest—than is the employer or the insurance company or companies designated by the employer. Second, it leads employees to take a larger fraction of their total remuneration in the form of medical care than they would if spending on medical care had the same tax status as other expenditures."

This is exactly what we saw in the "Shuffle." When Daniel's mother's "blue chip" Kentucky insurance became the valuable asset - not Daniel's actual need for recovery - the system had been completely inverted. The insurer, not the patient or family, became the de facto decision-maker about what treatment to provide. And because it was "somebody else's money," none of the parties had the same incentive to ensure the treatment actually worked.

On the transformation of insurance, Friedman observed:

"We generally rely on insurance to protect us against events that are highly unlikely to occur but that involve large losses if they do occur—major catastrophes, not minor, regularly recurring expenses. We insure our houses against loss from fire, not against the cost of having to cut the lawn. We insure our cars against liability to others or major damage, not against having to pay for gasoline. Yet in medicine, it has become common to rely on insurance to pay for regular medical examinations and often for prescriptions."43

The ACA's designation of addiction treatment as an essential health benefit with no caps was the logical endpoint of this distortion: treating predictable, ongoing care needs as if they were unpredictable catastrophes, and creating unlimited entitlements that - predictably - got exploited.

The Historical Counterfactual

Friedman estimated that if the pre-World War II system had continued and if the tax exemption and Medicare and Medicaid had never been enacted then expenditures on medical care would have amounted to less than half the current level, which would have put the United States near the bottom of the OECD list in healthcare spending rather than at the top.44

We can't know if that estimate is precisely correct. But the direction is almost certainly right. The 1942 accident fundamentally broke the relationship between patients, providers, and payment. Everything that followed - from job lock to the Shuffle to exploding costs - flows from that initial distortion.

Why This Matters

I'm not suggesting progressives should suddenly become libertarians. Friedman's prescription - minimal government, maximum markets - has its own blind spots, particularly around how to ensure universal access and protect vulnerable populations.

But Friedman's diagnosis is correct: our current system is not a "free market" at all. It's a corporatist hybrid where government tax policy creates massive subsidies that flow through employers, where regulatory capture protects incumbents, where third-party payment eliminates price signals and accountability.

Both progressives and libertarians should be able to agree: this is the worst of both worlds. We have achieved neither the solidarity and universality of social democracy nor the efficiency and dynamism of genuine markets. We've created a system where:

• Workers are trapped in jobs for health coverage (not free market)

• Costs explode with no price signals (not free market)

• Regulatory capture protects monopolies (not free market)

• Yet people still go bankrupt from medical bills (not social democracy)

• Vulnerable people are systematically exploited (not social democracy)

• Health outcomes lag peer nations (not social democracy)

The path forward requires recognizing that markets and government aren't opponents - they're complementary tools that work best when deployed strategically. Markets excel at discovering efficient solutions when consumers have good information and real choice. The government excels at ensuring universal access and protecting against catastrophic risks.

The question isn't "market or government?" The question is: "How do we design a system that uses each tool where it works best?"

The Preventive Care Paradox: Why We Spend More and Get Less

One of the most damning indictments of the American healthcare system is what we might call the Preventive Care Paradox. The United States spends $589 per capita annually on preventive care which is 38% more than the $426 average of comparable wealthy nations.45 Yet despite this higher spending, Americans suffer from significantly higher rates of precisely the conditions that preventive care is supposed to prevent: the highest obesity rates among developed nations, the highest rates of diabetes and hypertension, and more hospital admissions for preventable complications of chronic diseases.

The problem isn't medical knowledge - we know that intensive lifestyle interventions can reduce Type 2 diabetes incidence by 58%, with a return on investment of roughly $50 in savings for every dollar spent.46 The problem is that prevention represents less than 3% of total healthcare spending, dwarfed by treatment costs, and the employer-based insurance system ensures no one captures the return on prevention investments.

The core issue is incentive misalignment. The average American worker changes jobs, and therefore health insurers, on average every 4.1 years.47 If an insurer invests $4,000 in an intensive diabetes prevention program for a 45-year-old employee today, the $200,000 in avoided treatment costs won't materialize until 2035 or 2040, when that person will almost certainly be covered by a different insurer or by Medicare. The entity that paid for prevention captures none of the benefit - a competitor or the taxpayer reaps the reward. This creates systematic underinvestment in effective long-term health interventions.

Compare this to stable universal systems: in the Netherlands and Germany, where citizens remain with insurers for decades or life, insurers invest heavily in prevention because they'll capture future savings. Singapore's lifelong catastrophic coverage achieves some of the world's best preventive outcomes at 4.5% of GDP precisely because the system aligns incentives properly.48 Universal Catastrophic Coverage would solve this by making coverage permanent and portable. When the same entity pays for both prevention today and treatment decades from now, investing in prevention becomes rational rather than wasteful.

The Singapore Model: Proof of Concept

Before outlining the specific proposal for the United States, it's worth examining the one healthcare system in the world that most closely embodies the synthesis of universal security and market efficiency: Singapore.

Singapore achieves universal coverage while spending just 4.5% of GDP on healthcare49- less than half of what European single-payer systems spend, and a quarter of America's 16.7%. Yet Singapore's health outcomes match or exceed those of any Western nation. How?

The foundation is a catastrophic coverage system called MediShield Life, which covers all citizens for major hospitalizations and procedures above a certain threshold. But for routine care, Singapore uses mandatory Health Savings Accounts (called MediSave) that citizens fund throughout their working lives. For the poor and elderly, the government tops up these accounts directly.

The result is a system where patients are price-conscious consumers for routine care (driving competition and efficiency) but protected from financial ruin in catastrophic cases. Hospital price lists are published and transparent. Doctors compete on price and quality. Generic drugs dominate the market.

Critics point out that Singapore is small, culturally homogeneous, and authoritarian. Let's concede those points at face value, but the underlying economic logic isn't culturally specific. When patients spend their own money (even if that money came from mandatory savings), they shop around. When they're protected from bankruptcy, they don't skimp on necessary care. This combination creates the incentive structure for an efficient, humane system.

The Singapore model isn't perfect for America as our scale and diversity require adaptations. But it proves that the fundamental architecture of catastrophic coverage plus market-based routine care can work in practice, not just in theory.

The Synthesis: Universal Catastrophic Coverage with Market-Based Routine Care

How do we reconcile the progressive demand for universal security with the need for market efficiency demonstrated by the Shuffle? And how do we avoid creating new exploitation machines while trying to help people? The answer lies in a policy architecture that Samuel Hammond calls the "Free-Market Welfare State."50

The solution is not to nationalize the hospitals (the British model) or to mandate private insurance purchase (the Obamacare model). The solution is Universal Catastrophic Coverage (UCC)—a system that learns from both the failures we've documented and the successes other nations have achieved. This approach offers a "Grand Bargain" that solves the structural flaws of 1942 while fulfilling the moral obligation of 2025, and specifically avoids the perverse incentives that enabled the "Shuffle."

The High Floor: Abolishing Bankruptcy

Under Hammond's proposed model, the federal government offers a simple, ironclad guarantee: No American household will ever spend more than 10% of their income on healthcare.

If you are poor, that threshold might be near zero. If you are middle class, it is manageable. But once you hit that limit, the government fully picks up the tab.

Here's how it would work mechanically:

• Income-Based Threshold: Every household files taxes reporting their income. Their maximum annual healthcare liability is calculated as 10% of adjusted gross income.

• Real-Time Tracking: Healthcare providers report all charges to a centralized clearinghouse (similar to how Medicare claims are processed now). Once a household hits their threshold, a flag goes up in the system.

• Automatic Coverage: After the threshold is reached, all additional healthcare costs for that year are billed directly to the UCC program. The patient pays nothing.

• Progressive Floor: For households below 150% of the poverty line, the threshold is reduced to 2% of income. For those below the poverty line, it's zero—all care is covered from the first dollar.

This is a progressive victory. This is true universality. It eliminates the fear of medical bankruptcy instantly. It covers everyone, regardless of job status, pre-existing conditions, or age. A gig worker with leukemia gets the same protection as a Fortune 500 executive. It is the safety net the Left has dreamed of for a century.

Consider what this means for the working poor. A family of four making $45,000 a year would have a maximum healthcare liability of $4,500. If their child is diagnosed with cancer requiring $200,000 in treatment, they pay $4,500 and the government pays the rest. They don't negotiate with insurance adjusters. They don't fight claim denials. They don't lose their house.

The Open Market: Restoring Price Signals and Avoiding the "Shuffle" Trap

Crucially, for all expenses below that catastrophic threshold, we allow a genuine market to flourish. By repealing the 1943 tax exclusion for employer plans, we can redirect those billions into funding the UCC and expanding Health Savings Accounts (HSAs) for every citizen.

Here's the replacement architecture - designed specifically to avoid the problems revealed by the "Shuffle":

1. Universal HSAs with Patient Control

   1. Every American receives a Health Savings Account funded with a refundable tax credit

   2. The amount is income-adjusted: a low-income family might receive $4,000 per year, while a high-income family receives less or nothing

   3. Critical difference from current system: Patients control and spend their own HSA funds for routine care, creating cost consciousness

   4. This eliminates the "Shuffle" dynamic: When patients spend their own HSA money (even if government-provided), they have every incentive to seek effective treatment rather than prolonged cycling

2. Rollover and Investment

   1. Funds roll over indefinitely and can be invested, building a healthcare nest egg over time

   2. This creates long-term thinking - your HSA at 30 might pay for care at 70

   3. Patients have incentive to spend wisely because savings benefit them directly

3. Market Competition with Outcome Focus

   1. For all routine care (checkups, prescriptions, minor procedures) you spend from your HSA or out-of-pocket

   2. Providers must compete for your business by posting transparent prices and delivering quality care

   3. In addiction treatment specifically, this would reward facilities with actual recovery rates

   4. No unlimited entitlements: Once your HSA is exhausted (for routine care), you hit the catastrophic threshold - but the limit itself creates discipline

Why This Avoids the "Shuffle" Problems

Limited, Not Unlimited Coverage Below Threshold

Unlike ACA essential health benefits with no caps, routine care is funded through finite HSA dollars. A patient cycling through unnecessary detox would exhaust their HSA, creating natural discipline and forcing both patient and family to evaluate whether the treatment is actually working.

No Medical Loss Ratio Perversity

The government catastrophic program doesn't face MLR requirements that incentivize high spending. It simply covers costs above the threshold. There's no systematic incentive for fraud because there's no pressure to "spend enough to meet quotas."

Patient Cost-Consciousness Returns

Even though HSA funds are government-provided for low-income families, once deposited they belong to the patient. Spending $5,000 on a dubious urine test means $5,000 less available for other care—the patient becomes an active monitor of value, not a passive recipient.

As Friedman observed, people don't spend someone else's money as carefully as their own. But under UCC, even government-provided HSA funds become the patient's own money once deposited. The psychological and practical difference is enormous.

Outcome-Based Competition

Treatment centers competing for HSA dollars would need to demonstrate results. Centers with high relapse rates would lose business to those with actual recovery success. The financial incentive shifts from "keep them cycling" to "actually help them recover so they recommend us to others."

Fraud Becomes Unprofitable

The elaborate schemes in "Shuffle" only worked because insurers faced perverse incentives to tolerate fraud (MLR requirements) and patients were completely insulated from costs. Under UCC, fraudulent providers simply don't get paid - patients spending their own HSA dollars won't choose providers known for exploitation.

The Example: Surgery Center of Oklahoma

This isn't theoretical. The Surgery Center of Oklahoma operates on exactly this model today.51 By refusing to accept insurance and instead posting transparent, all-inclusive prices online, they've driven down costs dramatically. A knee arthroscopy that costs $25,000 at a traditional hospital costs $4,500 at their facility - same quality, same outcomes, 80% discount.

Why? Because they have to compete for self-paying customers. Imagine that model spreading across the country. Urgent care clinics advertising "$49 strep test, results in one hour." Primary care physicians offering "$89 comprehensive physical with same-day appointments." Addiction treatment centers will be able to compete on actual recovery rates rather than billing codes.

The Logic: As Friedman recognized, insurance is for catastrophes; markets are for maintenance. We don't insure our oil changes or grocery purchases because that would make them expensive and bureaucratic. The same principle applies to routine healthcare.

The "Lock-in" Break: Freedom for the Worker

Most importantly, this model severs the link between employment and healthcare. Your UCC coverage and your HSA belong to you, not your boss.

The Economic Boom: This effectively deregulates the American labor market. A worker can leave a stagnant corporate job to start a business, join a gig platform, or care for a family member without risking their health coverage. It ends the era of "Job Lock" and restores the dynamism of the American workforce.

The macroeconomic effects would be substantial. Right now, an estimated 2-3 million Americans remain in jobs they would otherwise leave specifically because of healthcare benefits. These are workers who would otherwise start businesses, pursue education, or move to better opportunities. The Kauffman Foundation estimates that health insurance reform of this type could increase new business formation by 15-25%, unleashing a wave of entrepreneurial activity.

Labor market fluidity would also increase dramatically. Workers could more easily move from declining industries to growing ones, from low-productivity to high-productivity employers, from jobs that are a poor fit to jobs that match their skills. This kind of dynamic labor reallocation is essential for long-term economic growth, but it's severely hampered when switching jobs means risking your family's health coverage.

Union organizers would also benefit. Right now, workers at non-union employers are often terrified to unionize because they fear losing health benefits during a strike or lockout. With portable, individual

coverage, that fear evaporates. The balance of power between labor and capital shifts back toward workers.

By combining a socialist floor (universal protection from ruin) with a capitalist engine (price competition for routine care), we create a system that is both humane and sustainable. We stop subsidizing the "company store" and start empowering citizens.

The Supply-Side Revolution: Breaking the Monopolies

Universal Catastrophic Coverage solves who pays and how much (the demand side). But we cannot achieve sustainable costs without addressing the supply side: the artificial scarcity built into our system through decades of regulatory capture.

A comprehensive package reform must include the following policies:

1. Repeal Certificate of Need Laws

The federal government should use its spending power to force states to eliminate CON laws. Any state that maintains barriers to healthcare facility construction should lose a percentage of its Medicaid matching funds. This is the same mechanism the federal government used to establish a national drinking age, therefore it's constitutionally sound and politically effective.

Within five years of CON repeal, we should expect to see:

• A 15-20% increase in hospital beds in currently underserved areas

• New specialty surgical centers competing with incumbent hospitals

• Community health clinics opening in neighborhoods previously served only by expensive emergency rooms

• Prices for common procedures falling by 10-15% due to increased competition

As Robert Orr's research demonstrates, repealing CON laws would be particularly transformative for access to advanced medical technology. The "superior good" problem would be solved: as MRI machines, specialized surgical equipment, and diagnostic technology improve, they could rapidly proliferate to independent centers and community hospitals rather than remaining concentrated in

incumbent systems. This would dramatically reduce wait times for advanced imaging and specialized procedures while driving down costs through competition.

2. Full Practice Authority for Nurse Practitioners and Physician Assistants

Federal law should establish that any healthcare provider licensed in one state can practice in all states, and that NPs and PAs can practice to the full extent of their training without physician supervision. The mechanism: make full practice authority a condition of receiving Medicare reimbursement.

The American Association of Nurse Practitioners estimates this would effectively add 120,000 primary care providers to the workforce overnight by freeing providers who are already trained and credentialed but currently restricted from practicing independently.52

3. Eliminate the Residency Cap and Streamline Foreign Physician Licensing

Following Robert Orr's research, we must immediately lift the 1997 Medicare residency funding cap. Congress should authorize funding for an additional 15,000 residency positions per year, with priority given to primary care, rural medicine, and specialties facing the most severe shortages. This would eliminate the absurd situation where qualified medical school graduates cannot complete their training due to an arbitrary 30-year-old budget decision.

Simultaneously, we must streamline licensing for foreign-trained physicians. Doctors who completed medical school and residency at accredited institutions in developed countries (UK, Canada, EU nations, Australia, Japan, etc.) should be able to practice in the United States after passing a single comprehensive examination and completing a brief orientation to U.S. healthcare systems. The current requirement that they repeat years of residency training serves no patient safety purpose and simply protects incumbent physicians from competition.

These reforms alone could increase physician supply by 25-30% within a decade, dramatically reducing wait times and costs while improving access in underserved areas.

4. Mutual Recognition of Drug Approvals

The United States should immediately recognize any drug approved by the European Medicines Agency, the UK's MHRA, Japan's PMDA, or Australia's TGA. If a drug is safe enough for a German patient, it's safe enough for an American patient.

This doesn't mean abolishing the FDA, it means ending duplicative testing that serves no safety purpose. The FDA would maintain post-market surveillance, adverse event reporting, and manufacturing inspections. But it would stop requiring pharmaceutical companies to repeat clinical trials that have already been conducted to the same scientific standards abroad.

The impact: Drugs would reach American patients 1-2 years faster on average, and development costs would fall by an estimated 30%, savings that would be passed on to consumers through generic competition.

5. Price Transparency Requirements

Every hospital, clinic, and physician's office should be required to post transparent, all-inclusive prices for common procedures. These must be actual prices that patients can compare before choosing a provider - not "estimated ranges" or "depending on insurance".

The Trump administration's price transparency rules, implemented in 2021, were a good start but are poorly enforced.53 We need transparency with enforcement: hospitals that fail to post prices should lose their Medicare provider status. Within two years, patients should be able to Google "MRI prices near me" and get a list of facilities with posted prices, the same way they can compare prices for any other service.

Financing the Transition

The most reflexive objection to universal coverage is always the same: "How do we pay for it?" This question rests on a fundamental misunderstanding of our current reality. We are not suffering from a lack of spending; we are suffering from a crisis of allocation. The United States is already paying for a universal system - we just aren't getting one. The federal government currently pours approximately $1.5 trillion annually into the healthcare sector:

• Medicare: $900 billion

• Medicaid: $450 billion

• Employer health insurance tax exclusion: $280 billion (in foregone revenue)

• Veterans Affairs: $100 billion

• Other programs: $70 billion

Additionally, state governments spend roughly $350 billion on Medicaid.

Universal Catastrophic Coverage Model Budget

A Universal Catastrophic Coverage system would cost approximately $1.3 trillion annually in steady state, according to estimates by the Niskanen Center.54 This is less than we currently spend because:

1. Administrative Efficiency: A single catastrophic coverage program has far lower overhead than the current patchwork of Medicare, Medicaid, employer plans, and individual market insurance.

2. Reduced Moral Hazard: When patients spend their own HSA dollars on routine care, they consume more efficiently - fewer unnecessary tests, more generic drugs, more preventive care.

3. Supply-Side Reforms: Breaking healthcare monopolies through CON repeal and scope-of-practice reform would reduce prices by an estimated 12-18% across the board.

To fund UCC, the plan would adopt the following:

1. Eliminate the employer health insurance tax exclusion (saves $280 billion)

2. Consolidate Medicare and Medicaid into UCC (reallocates $1.35 trillion)

3. Implement a modest 4% Value-Added Tax (VAT) (raises $250 billion)

The VAT is regressive, but we can make the overall package progressive by pairing it with the income-adjusted UCC threshold and expanded HSA funding for low-income families. A poor family would pay perhaps $200 more annually in VAT but receive $3,000 more in HSA funding and complete catastrophic protection yielding a massive net benefit.

The Transition Period

Moving from our current system to UCC can't happen overnight. A realistic transition would occur over 7-10 years:

Years 1-3: Pilot programs in 3-5 states, voluntary opt-in for existing Medicare/Medicaid recipients. Begin phasing out the employer tax exclusion by reducing the exclusion cap by 20% per year.

Years 4-6: Expand UCC to all states. Existing employer plans can continue, but they no longer receive tax advantages. Most employers begin shifting to "defined contribution" models where they fund employee HSAs instead of buying insurance.

Years 7-10: Full implementation. Medicare and Medicaid are fully integrated into UCC. The employer-based insurance market has largely dissolved, replaced by individual HSAs for routine care and UCC for catastrophic events.

During the transition, no one loses coverage involuntarily. Existing Medicare and Medicaid beneficiaries can keep their current arrangements if they prefer. The goal is to make the new system so obviously superior that people choose to switch.

Addressing Common Objections

"People Can't Shop for Healthcare"

Healthcare isn't like buying a TV - you can't compare prices when you're having a heart attack. This is absolutely true for catastrophic care, which is precisely why catastrophic care is covered by UCC regardless of cost. You don't shop for cancer treatment; the government pays for it.

But most healthcare spending is not emergency care. The Kaiser Family Foundation estimates that 60% of healthcare spending is on predictable, routine care: annual checkups, prescription refills, physical therapy, diabetes management, mental health counseling.55 These are services you can absolutely shop for, and making them subject to market competition would dramatically lower costs.

The experience of the Surgery Center of Oklahoma, direct primary care practices, and pharmacy discount programs like GoodRx demonstrates that when providers have to compete for patients paying directly, prices fall and quality rises.

"What About People Who Can't Afford the 10% Threshold?"

For truly poor families, the threshold can be reduced to 2% or even 0%. And crucially, the HSA tax credit provides upfront funding so that low-income families aren't paying out-of-pocket for routine care either.

Under the plan, a single mother making $25,000 would have:

• Maximum annual healthcare liability: $500 (2% of income)

• Annual HSA funding: $3,500 (from the refundable tax credit)

In practice, she'd almost never hit the $500 threshold because the HSA covers her routine care. And if her child develops leukemia, everything above $500 is covered by UCC.

"Won't HSAs Just Benefit the Wealthy?"

Current HSAs do disproportionately benefit the wealthy because only people with high-deductible insurance plans can open them, and only people with spare cash can fund them. Under this proposal, every American gets an HSA funded by the government, with more generous funding for the poor. It flips the current regressive system on its head.

"What Stops Providers from Price Gouging?"

Competition. Right now, providers can charge $20,000 for an MRI because patients don't know the price until after the procedure, and insurance pays it regardless. When patients spend their own HSA dollars, they demand price transparency and shop around. Providers who price gouge lose business to competitors.

We see this dynamic in procedures that insurance doesn't cover—look at cosmetic surgery and LASIK. Prices have fallen 30-40% in real terms over the past two decades while quality has improved, precisely because providers compete for self-paying customers.56

"What About Rural Areas Without Competition?"

This is a real concern, and it's why supply-side reforms are essential. CON repeal would make it easier to open clinics in underserved areas. Telemedicine expansion (which exploded during COVID) provides a competitive alternative even in areas with limited local providers.

Additionally, the UCC threshold means that even in rural areas with limited competition, families are protected from financial ruin. If the only hospital in your county charges high prices, you might pay more in routine care, but you'll never pay more than 10% of your total income.

"What About Wait Times?"

The specter of Canadian-style wait times is often raised as an argument against universal coverage. But the data tells a nuanced story that actually strengthens the case for UCC.

First, it's important to acknowledge that wait times in single-payer systems like Canada and the UK are real and serious. Canada's median wait time from GP referral to treatment reached an unacceptably long 30 weeks in 2024.57 The UK's NHS has failed to meet its standards since 2015. These delays cause suffering and, in some cases, allow conditions to worsen unnecessarily.

However, the assumption that America has superior access is largely a myth. Data shows that 51% of US patients can see a provider within a day, compared to 67% in Australia, 56% in France, and 53% in Germany. When it comes to specialized tests, 30% of US doctors report that their patients have difficulty obtaining them, compared to just 11% in Australia and 15% in Sweden.58

The critical insight is that wait times in Canada and the UK result from chronic political underfunding and supply constraints, not from the universal coverage model itself. Germany, France, and the Netherlands achieve both universal coverage and access times equal to or better than the United States while spending 10-12% of GDP versus America's 16.7%.59 They prove that universality doesn't require rationing by delay.

The US already rations healthcare - we just do it through financial barriers rather than wait times. About 25% of Americans struggle to pay medical bills,60 and millions delay or skip care entirely due to cost. This is rationing by another name, and it's arguably crueler because it falls hardest on those least able to afford it.

UCC avoids the wait time problem through its unique architecture. By maintaining market-based routine care with price competition, we preserve the supply response that prevents queues for everyday services. For catastrophic care covered by UCC, the government can negotiate prices without artificially constraining supply because the supply-side reforms dramatically increase provider capacity.

The Political Economy: Why This Hasn't Happened

If this synthesis of universal security and market efficiency is so obviously superior, why hasn't it already happened? The answer lies in the political economy of the current system - the concentrated interests that benefit from the status quo and the diffuse public that bears the cost.

The Insurance Industry

The private health insurance industry generates $1.2 trillion in annual revenue and employs over 500,000 people.61 These companies have a vested interest in maintaining the employer-based system, where they serve as the middleman between patients and providers, extracting administrative rents. But here's the twist: the insurance industry should actually support this reform. Under UCC, there's still a role for private insurance to provide supplemental coverage for services below the catastrophic threshold, concierge medicine, and international coverage. What disappears in this model is the inefficient, bureaucratic employer-based group market that insurers themselves complain about constantly.

Several major insurers have quietly indicated they would support a move toward individual HSAs and catastrophic coverage, because it would eliminate the "race to the bottom" in employer plan pricing and reduce their administrative burden.

Hospital Systems

Large hospital monopolies are the most powerful opponents of reform. Organizations like HCA Healthcare and CommonSpirit Health generate tens of billions in revenue by maintaining artificial scarcity through CON laws and charging opaque, inflated prices to insured patients.

Breaking their monopoly is essential, which means confronting them politically. This requires a coalition of:

• Small employers tired of double-digit annual premium increases

• Labor unions that could negotiate higher wages if health benefits weren't so expensive

• Rural communities shut out of healthcare access by urban hospital systems blocking competition

• Fiscal conservatives angry about the $280 billion employer tax exclusion

The AMA and Medical Guilds

The American Medical Association represents physicians' economic interests, and those interests are threatened by scope-of-practice reform and residency expansion. But the AMA only represents about 15% of American physicians and most doctors aren't even members.62

Increasingly, younger physicians support expanding NP and PA practice authority because they don't want to waste their time on routine cases anyway.

The key is splitting the medical profession between high-earning specialists (who benefit from scarcity) and primary care doctors (who are overwhelmed and understaffed). Primary care physicians would be natural allies of this reform.

Why Unions Have Supported the Status Quo

Historically, unions have defended employer-based healthcare because they negotiated those benefits in collective bargaining and view them as a hard-won victory. Walter Reuther's famous quote about healthcare being part of the "social contract" reflects this mindset.

But the landscape has shifted. Union density has collapsed from 35% in the 1950s to 10% today.63 Most workers aren't covered by union-negotiated plans anymore; they're at the mercy of whatever their employer offers. And union workers themselves are increasingly frustrated by rising premiums and out-of-pocket costs that eat into wage increases.

Modern unions like SEIU and the Teachers Federation have begun signaling openness to Medicare for All precisely because employer-based coverage no longer serves workers well. The political opportunity exists to bring unions into a coalition for UCC by emphasizing worker freedom and the end of job lock.

The Cadillac Tax Fight as a Case Study

The Affordable Care Act included a provision taxing high-cost employer health plans (the so-called "Cadillac Tax"), precisely to begin unwinding the employer tax exclusion. It was the right policy with aims of reducing the subsidy for expensive insurance and generating revenue for subsidies. But the Cadillac Tax never went into effect. It was delayed repeatedly and finally repealed in 2019 because of a massive lobbying campaign by unions, corporations, and insurers.64 This coalition argued that taxing health benefits would hurt the middle class.

They were right, but only because the tax wasn't paired with an alternative. Workers didn't want to lose their tax-free health benefits without getting something better in return. This is why UCC must be a replacement, not just a repeal. Give workers something better in the form of portable HSAs and catastrophic protection and they'll support ending the employer tax exclusion.

Learning from International Models

While the Singapore model provides the closest template, it's worth examining other international systems to understand what works and what doesn't.

Switzerland: Regulated Private Insurance

Switzerland mandates that all citizens purchase private health insurance, with subsidies for low-income families. Insurers compete for customers, and there is no employer-based insurance system.

What works: Switzerland achieves universal coverage with a private insurance market. Portability is complete - your insurance belongs to you, not your employer. Costs are controlled through government regulation of premiums.

What doesn't work: Swiss healthcare is the second most expensive in the world after the U.S. (11.3% of GDP).65 Heavy regulation creates bureaucracy without the market discipline of genuine price competition. Patients still don't see transparent prices for routine care.

Lesson: Mandating private insurance achieves universality but doesn't control costs without supply-side reforms.

Germany: The Bismarck Model

Germany uses a "sickness fund" system where workers and employers pay into non-profit insurance funds, with the government covering those unable to work.

What works: Universal coverage with a mix of public and private options. Strong cost controls through centralized negotiation of prices with providers. Good health outcomes at moderate cost (11.7% of GDP).66

What doesn't work: The system is still employment-based, creating some degree of job lock. The multi-payer structure creates administrative complexity. Prices are controlled through negotiation rather than competition, which can limit innovation.

Lesson: Employment-based systems can achieve universality, but they sacrifice labor market flexibility and rely on bureaucratic price-setting rather than market discovery.

Canada: Single-Payer with Private Delivery

Canada's Medicare system is government-funded but relies on private physicians and hospitals for delivery. The government is the single payer, negotiating prices centrally.

What works: True universality with no out-of-pocket costs at point of service. Complete portability - your coverage follows you regardless of employment. Lower costs than the U.S. (10.8% of GDP).67

What doesn't work: Long wait times for non-emergency procedures (median wait time of 30 weeks from GP referral to treatment in 2024). Limited supply of care due to government budget constraints and inadequate physician supply. No price signals to guide efficient resource allocation.

Lesson: Single-payer achieves equity but struggles with efficiency when supply constraints aren't addressed which is a problem UCC solves through supply-side reforms.

The UK: Fully Socialized Medicine

Britain's NHS is government-owned and operated. Doctors are government employees, hospitals are government property.

What works: Extremely cheap (10.3% of GDP).68 True universality. Strong preventive care and public health outcomes.

What doesn't work: Chronic underfunding leading to deteriorating infrastructure. Wait times are even longer than in Canada. Limited patient choice. Political games - healthcare quality depends on which party controls the government and how generous they feel.

Lesson: Full socialization creates intense cost control but makes the system vulnerable to political whims and underinvestment.

What America Can Learn

Each system makes tradeoffs. Canada and the UK prioritize equity over efficiency. Switzerland and Germany prioritize choice over cost control. Singapore alone successfully balances universality, efficiency, and cost containment.

The American system must work with American culture: our distrust of government monopolies, our entrepreneurial spirit, our diversity and scale. A system that works for Sweden (population 10 million, culturally homogeneous, high social trust) might fail in America (population 335 million, culturally diverse, lower institutional trust).

The UCC model is designed specifically for the American context: universal security (satisfying the progressive impulse), individual choice (satisfying the libertarian impulse), and competition-driven efficiency (satisfying the fiscal conservative impulse).

The Innovation Question: How Do We Maintain Medical Progress?

One of the strongest arguments against government-run healthcare is the innovation concern: America accounts for roughly 40% of global pharmaceutical R&D spending despite being only 4% of the world's population.69 American medical device innovation is similarly dominant. Does this system, for all its flaws, subsidize innovation that benefits the entire world?

This is a serious question that progressives often dismiss too quickly. But the answer isn't to preserve the current system, it's to design a better one that maintains innovation incentives while providing universal coverage.

The Current Innovation Story (and Its Problems)

The pharmaceutical industry's argument goes like this: High American drug prices fund R&D. Other countries free-ride by imposing price controls, forcing companies to make profits in the U.S. market. If America adopts price controls or single-payer, innovation will grind to a halt.

There's some truth here, but it's heavily exaggerated:

1. Most basic research is publicly funded. The NIH spends $45 billion annually on medical research70- far more than any private company. Breakthrough drugs often originate from NIH-funded university research; pharmaceutical companies primarily fund the expensive clinical trial process.

2. Marketing exceeds R&D spending. The pharmaceutical industry spends more on marketing and lobbying ($83 billion annually) than on research ($68 billion).71 Much R&D spending goes to "me-too" drugs resulting in slight modifications of existing medications designed to extend patent protection rather than genuine innovation.

3. High prices don't guarantee innovation. Insulin was discovered over 100 years ago and costs pennies to manufacture, yet it costs $300 per vial in America. These profits aren't funding innovation; they're funding rent extraction.

That said, genuine innovation does require funding. Cancer immunotherapies, gene therapies, and breakthrough antibiotics require billion-dollar investments with high failure rates. How does UCC maintain these incentives?

How UCC Preserves Innovation

Catastrophic Coverage Rewards True Breakthroughs

Under UCC, the government pays for catastrophic care which includes expensive breakthrough treatments. A new cancer drug that costs $150,000 per year would be covered by UCC for patients who reach their income-based threshold. The manufacturer still gets paid; they're just negotiating with a single payer (the government) rather than multiple insurance companies.

This actually focuses innovation incentives on high-value treatments. Right now, pharmaceutical companies can make money through genuine breakthroughs (good), incremental "me-too" drugs (wasteful), and marketing campaigns that convince doctors to prescribe expensive brands over cheap generics (harmful).

Under UCC with HSA-funded routine care, patients paying out-of-pocket for maintenance medications will demand generics and cheaper alternatives. This makes the "me-too drug" strategy less profitable. But breakthrough drugs for catastrophic conditions still get rewarded handsomely because the government will pay for them.

Patent Reform and Prize Systems

We should pair UCC with patent reform. Currently, pharmaceutical patents last 20 years but often don't start being used until 10+ years have passed due to clinical trials. This creates perverse incentives to rush drugs to market before testing is complete.

A better system: Extend effective patent life for genuine innovations while offering large government prizes for breakthrough drugs that meet specific public health goals. For example: $5 billion prize for a cure for Alzheimer's, $2 billion prize for a new class of antibiotics effective against resistant bacteria, $1 billion prize for a universal flu vaccine.

This "prize plus patent" model maintains innovation incentives while reducing the need for extreme pricing.

Supply-Side Reforms Enable Innovation

Here's an underappreciated point: the current system stifles healthcare innovation outside of pharmaceuticals. CON laws prevent innovative delivery models like micro-hospitals or specialized surgery centers. Scope-of-practice restrictions prevent innovations in care delivery like pharmacy-based clinics or NP-led preventive care programs.

The Surgery Center of Oklahoma is an efficient, transparent, and high-quality innovation in healthcare delivery. But it's illegal to replicate in 35 states without fighting incumbent hospitals in CON hearings. How much innovation are we missing because of these restrictions?

UCC paired with supply-side deregulation would unleash an explosion of innovation in care delivery, not just pharmaceuticals. We'd see new models of primary care, innovative urgent care clinics, telemedicine platforms, AI-assisted diagnostics, and more.

Building the Political Coalition

Healthcare reform has failed repeatedly in American history, most recently with the half-measure that was the Affordable Care Act. Why would UCC succeed where other reforms have failed? The answer lies in building an unusual coalition that cuts across traditional partisan lines.

The Left: Freedom from Fear

Progressives should embrace UCC because it achieves the core goal of the welfare state: decommodifying essential human needs. No one will lose their home because of cancer. No one will ration insulin. No one will delay necessary surgery because they can't afford it.

The fact that routine care remains market-based is a feature, not a bug. It ensures sustainability and efficiency while maintaining the universal guarantee that matters: protection from catastrophic costs.

The Libertarian Right: Freedom to Choose

Conservatives and libertarians should embrace UCC because it dismantles corporate welfare and restores genuine markets. The $280 billion employer tax exclusion is one of the largest corporate subsidies in the federal budget. Repealing it and redirecting the funds to individual citizens is fundamentally pro-market.

Small Business: Relief from Burden

Small businesses are crushed by healthcare costs. Under UCC, small businesses are freed from this burden entirely. They can compete for workers on wages and working conditions rather than insurance quality.

Labor Unions: Real Bargaining Power

With UCC, unions can negotiate for higher wages rather than fighting to preserve existing health benefits. Job lock disappears, making it easier for workers to leave non-union employers.

The Tech Industry: Enabling Entrepreneurship

Silicon Valley should embrace this reform enthusiastically. Job lock is a massive barrier to entrepreneurship. The Kauffman Foundation estimates that comprehensive healthcare reform could increase startup formation by 15-25%.

Conclusion: The Grand Bargain

For decades, the American healthcare debate has been paralyzed by a false choice between "Socialism" and "Freedom." The Right argues that government involvement stifles liberty, while the Left argues that market forces stifle humanity.

The tragedy is that under our current system (the accidental inheritance of 1942) we have achieved neither. We have a system that is sufficiently bureaucratic to stifle innovation, yet sufficiently ruthless to bankrupt the sick. We have sacrificed both liberty and security on the altar of the employer-based tax deduction.

We have documented three interrelated failures:

1. The 1942 Accident created corporate feudalism by tying healthcare to employment through a wartime tax loophole.

2. The Shuffle revealed what happens when we try to fix this through insurance subsidies alone - well-intentioned coverage expansion becomes an exploitation machine when grafted onto third-party payment structures with perverse incentives.

3. Supply-Side Regulatory Capture creates artificial scarcity through CON laws, scope-of-practice restrictions, residency caps, and FDA redundancy that drives up costs regardless of how we structure payment.

Even economists like Milton Friedman, whose free-market philosophy most progressives reject, identified the same corporatist distortion from a different starting point. The critique of third-party payment unites unlikely allies because it describes observed reality, not ideological preference.

The path forward requires us to recognize a fundamental truth that Samuel Hammond and other reformers have identified: Economic security and market dynamism are not opposites; they are partners.

The Grand Bargain is This

To the Progressive: You get true universality. No American will ever face medical bankruptcy. Coverage is permanent, portable, and comprehensive for catastrophic needs. The preventive care paradox is solved through lifelong coverage that aligns incentives. The vulnerable are protected from exploitation like we saw in the Shuffle.

To the Libertarian: You get genuine markets for routine care. Price transparency, competition, and consumer choice replace bureaucratic rationing. The $280 billion corporate welfare subsidy is eliminated. Supply-side reforms break monopolies. Friedman's vision of catastrophic-only insurance is realized.

To the Worker: You get freedom. Your healthcare is yours, not your employer's. The 40% reduction in entrepreneurship transitions caused by job lock disappears. You can organize, negotiate, and move without fear.

To the Fiscal Conservative: You get sustainability through competition and efficiency. Administrative costs are slashed. The long-term entitlement crisis is averted.

To Those in Recovery and All Vulnerable Populations: You get a system where providers must compete on actual outcomes rather than billing throughput. Recovery becomes the goal, not a "secondary concern." The financial incentive shifts from keeping you sick to actually helping you heal.

If we pair a universal catastrophic guarantee with a radically free market for routine care, and break the supply monopolies that drive scarcity, we will not just lower prices. We will unleash a new era of American dynamism. We will finally break the chains of the 1942 accident, creating a society where the worker is free to move, the innovator is free to build, the sick are free from fear - and where the vulnerable are protected from predatory schemes that profit from prolonging their suffering.

The American healthcare disaster was born from a bureaucratic accident in 1942. It has persisted for 83 years because we've been trapped in the false binary of "market or government." The answer has always been both: markets where they work best, governments where markets fail, and careful design to ensure that subsidies heal rather than harm.

Universal Catastrophic Coverage is that answer. It is the Grand Bargain. It is how we finally achieve the progressive dream of universal security without abandoning the American dream of individual freedom - and without creating the perverse incentives that turned addiction treatment into a trillion-dollar exploitation machine.

The only question remaining is whether we have the political courage and wherewithal to seize it.

References

1 Kaiser Family Foundation, "2025 Employer Health Benefits Survey," October 2025.

2Ibid.

3 Peterson-KFF Health System Tracker, based on OECD Health Statistics 2025.

4 Stabilization Act of 1942, 56 Stat. 765 (1942).

5 Thomasson, Melissa A. "From Sickness to Health: The Twentieth-Century Development of U.S. Health

Insurance." Explorations in Economic History 39, no. 3 (2002): 233-253.

6 War Labor Board meeting minutes, 1943-1945, National Archives.

7 Internal Revenue Code of 1954, Section 106.

8 UAW Convention Proceedings, 1955.

9 Congressional Budget Office, "The Distribution of Major Tax Expenditures in 2025," 2025.

10 Wellington, Alison J. "Health Insurance Coverage and Entrepreneurship." Contemporary Economic Policy 19, no. 4 (2001); Fairlie, Robert W., et al. "Is Employer-Based Health Insurance a Barrier to Entrepreneurship?"

Journal of Health Economics 30, no. 1 (2011).

11 Webster, Charles. The National Health Service: A Political History. Oxford University Press, 1998.

12 Blase, Brian. "The Great Obamacare Enrollment Fraud." Paragon Health Institute, 2024.

13 Blase, Brian. Panel discussion following screening of "Shuffle," Cato Institute, 2025.

14 Centers for Medicare & Medicaid Services, enrollment data analysis, August 2024, cited in Blase (2025).

15 Flaherty, Benjamin. Director's interview on "Shuffle," 2025.

16 Quinones, Sam. The Least of Us: True Tales of America and Hope in the Time of Fentanyl and Meth. Bloomsbury Publishing, 2021.

17 Cannon, Michael. Panel discussion following screening of "Shuffle," Cato Institute, 2025.

18Ibid.

19 Hammond, Samuel. "Cost Disease Socialism." Niskanen Center blog, 2018.

20 Peterson-KFF Health System Tracker, "How do healthcare prices and use in the U.S. compare to other countries?" 2024.

21 Mercatus Center, "Certificate-of-Need Laws: State by State," updated 2025.

22 National Health Planning and Resources Development Act of 1974; repealed by OBRA 1987.

23 Mitchell, Matthew D., and Christopher Koopman. "Certificate-of-Need Laws: Boon or Barrier?" Mercatus Research, 2020.

24 Beckworth, David, and Robert Orr. "Robert Orr on Supply Side Bottlenecks in the US Healthcare System." Macro Musings, Mercatus Center podcast, 2023.

25 American Association of Nurse Practitioners, "State Practice Environment," 2025.

26 Timmons, Edward J. "The Effects of Expanded Nurse Practitioner and Physician Assistant Scope of Practice." RAND Corporation, 2018.

27 OECD Health Statistics 2024, "Remuneration of Health Professionals."

28 Orr, Robert. "Unmatched: Repairing the U.S. Medical Residency Pipeline." Niskanen Center, February 2023; "The Planning of U.S. Physician Shortages." Niskanen Center, November 2023.

29 Balanced Budget Act of 1997, Pub. L. 105-33, § 4626.

30 National Resident Matching Program, "Results and Data: 2022 Main Residency Match," 2022.

31 Association of American Medical Colleges, "The Complexities of Physician Supply and Demand: Projections from 2021 to 2036," 2023.

32 Philipson, Tomas J., et al. "Assessing the Safety and Efficacy of the FDA." University of Chicago, 2017.33 DiMasi, Joseph A., et al. "Innovation in the pharmaceutical industry." Journal of Health Economics 47 (2016): 20-33.

34 Wellington (2001); Fairlie, et al. (2011).

35 Fairlie, Robert W. "Kauffman Index of Entrepreneurial Activity." Kauffman Foundation, 2013.

36 Bailey, James, and Anna Chorniy. "Employer-Provided Health Insurance and Job Mobility." Journal of Health

Economics 51 (2017).

37 Heim, Bradley T., and Ithai Z. Lurie. "The Effect of Self-Employed Health Insurance Subsidies." Journal of Public

Economics 94 (2010).

38 Wellington (2001).

39 Kauffman Foundation, "Healthcare Reform and Entrepreneurship," Research Brief, 2019. 40 Gruber, Jonathan, and Brigitte C. Madrian. "Health Insurance, Labor Supply, and Job Mobility." Handbook of Health Economics, vol. 1, 2000.

41 Kaiser Family Foundation, "2024 Employer Health Benefits Survey.

42 Friedman, Milton. "How to Cure Health Care." The Public Interest 142 (Winter 2001): 3-30.

43Ibid.

44Ibid.

45 OECD Health Statistics 2024, "Healthcare Expenditure by Function."

46 Diabetes Prevention Program Research Group. "10-year follow-up of diabetes incidence and weight loss." The

Lancet 374, no. 9702 (2009): 1677-1686.

47 Bureau of Labor Statistics, "Employee Tenure Summary," 2024.

48 Ministry of Health Singapore, "Healthcare System Overview," 2024.

49 OECD Health Statistics 2024.

50 Hammond, Samu Niskanen Center, 2018.

51 Surgery Center of Oklahoma, pricing data available at surgerycenterok.com.

52 American Association of Nurse Practitioners, "Nurse Practitioner Workforce," 2024.

53 Centers for Medicare & Medicaid Services, "Price Transparency Rule," implemented January 2021.

54 Hammond, Samuel. "Universal Catastrophic Coverage: A Fiscally Sustainable Path to Universal Health Care." Niskanen Center, 2019.

55 Kaiser Family Foundation, "Health Care Expenditures by Type of Service," 2023.

56 Makary, Marty, and Michael Daniel. The Price We Pay: What Broke American Health Care. Bloomsbury Publishing, 2019.

57 Fraser Institute, "Waiting Your Tel. "The Free-Market Welfare State."urn: Wait Times for Health Care in Canada, 2024 Report," 2024.

58 Commonwealth Fund, "Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System," 2024.

59 OECD Health Statistics 2024.

60 Kaiser Family Foundation, "Health Care Debt in the U.S.," 2024.

61IBIS World, "Health & Medical Insurance in the US," Industry Report, 2024.

62 Cain, Carol, and Monica Mittman. "AMA Membership Falls." American Medical News, 2011.

63 Bureau of Labor Statistics, "Union Membership Historical Data," 2024.

64 Further Consolidated Appropriations Act, 2020, Pub. L. 116-94 (repealing ACA Cadillac Tax).

65 OECD Health Statistics 2024.

66Ibid.

67Ibid.

68Ibid.

69 Evaluate Pharma, "World Preview 2024," pharmaceutical R&D spending by country.

70 National Institutes of Health, "Budget," Fiscal Year 2025.

71 Schwartz, Lisa M., and Steven Woloshin. "Medical Marketing in the United States, 1997-2016." JAMA 321, no. 1 (2019): 80-96.

Formatting in progress - original written as an assignment to argue in favor of medicare for all - it was given an A-... mission accomplished?