What would care cost?
Who would pay how much?

What would coverage cost—and how would we pay for it?

Removing unnecessary spending can reduce the budget. Making coverage affordable also requires redistributing that budget by ability to pay. These are two separate calculations.

Today’s prices are a starting point, not the destination. This analysis identifies opportunities to reduce spending and tests what affordable member payments could fund.

1. Separate care from insurance overhead

Source: CMS NHE Tables, Table 2. Nominal dollars. Subcategories can differ from the published total by rounding. Hospital and provider payments include their own overhead and margins; “personal healthcare” does not mean every dollar is efficient or clinically necessary. Hospital-administered drugs are included in provider categories, not the retail-drug line.

In 2024, national spending totaled $5.279T. The care subtotal was $4.510T; the remaining categories are shown above. Removing a category from the fund’s scope is not automatically a saving for society. Public health and capital still need funding somewhere.

Nonmedical insurance expenditures include more than profits. Eliminating that entire category is an unrealistic upper-bound exercise because a replacement fund still needs claims processing, systems, staff and advocacy. Provider billing savings are a separate opportunity within care payments.

2. What evidence supports savings?

• Negotiating provider prices: RAND found that sampled private plans paid about 254% of Medicare prices for hospital services in 2022. This supports investigating large reductions in commercial prices; it does not imply a 61% cut to all national spending. Medicare and Medicaid already pay different rates. RAND report.
• Drug middlemen: FTC documented over $7.3 billion above estimated acquisition cost on the specialty generics it examined during 2017–2022. This is evidence of a real pricing problem, not a national annual savings estimate. Acquisition-cost markups also are not identical to net profit. FTC findings.
• Whole-system reform: CBO’s five illustrative systems changed projected 2030 spending from a $743 billion decrease to a $290 billion increase against a $6.631 trillion baseline. Lower payment rates and administration reduced spending; greater use raised it. Its option including expanded long-term services and supports increased total spending. These are 2020 projections for government systems, not quotes for a private fund. CBO, Exhibit 1-1, printed page 12.
• A favorable universal-care study: Galvani and colleagues estimated about 13% net savings while expanding coverage. Its financing includes existing government allocations as well as employer/household money. That financing cannot simply be carried over to a member-only private fund. The Lancet, 2020.

Accounting rule: do not add insurer profit, shareholder dividends, executive salaries, administrative savings and PBM markups as if they were all independent. Some are nested in the same spending. Savings require identifying a payment once, reducing it once, and retaining the cost of necessary replacement services.

3. Test the $100 average

320,000,000 people × $100 × 12 = $384,000,000,000

That equals 9.2% of 2023 personal healthcare spending. Relative to that historical nationwide care subtotal, reaching $384 billion would mean a 90.8% reduction, before replacement fund operations, reserves or newly met needs. This is a scale comparison, not an actuarial estimate for citizens: the historical spending includes noncitizens, and 320 million is the proposed enrollment assumption.

Even an arithmetic stress test cutting all 2023 care payments in half leaves $2.081T. That 50% cut is not a forecast; it demonstrates how much more ambitious the $384 billion total is. Current spending is not a minimum-cost floor, but the reviewed evidence does not support a reduction of roughly nine-tenths.

4. Test payments against actual income

The IRS reports about $15.286T in 2023 adjusted gross income across 160.6 million returns. Using published brackets, income above a hypothetical $25,000 allowance per return totals $11.975T.

Policy experiment, not an adopted fund rule: exempt the first $25,000 of AGI on each return, then apply a single coverage-payment rate to the rest. The allowance is a transparent choice for this test; it is not a measured cost or a recommendation. Its effective burden rises with income.

Annual coverage payment = rate × max(0, AGI − $25,000)
Annual revenue = rate × $11.975T

*These are funding requirements to test, not estimates that care can be supplied for $1T, $2T or $3T. Dollar figures round to the nearest dollar. All calculations use 2023 reported income with full participation and collection.

A 3% rate produces exactly $100/month at $65,000 AGI. Applied to the IRS distribution it raises $359.3B a year. That is a demonstrated revenue result under this policy experiment, not enough evidence to promise coverage at that price.

Source: IRS SOI Table 1.2, tax year 2023, all returns. A return can represent one or two adults and dependents; it is not an individual member. IRS filers include noncitizens and omit nonfilers. AGI is not salary or all economic income. This is a financing feasibility proxy, not the final citizen-only, individual, age-and-income model.

5. Can $65,000 earners stay at $100/month?

Yes, in this funding model, by asking higher incomes to pay a larger share. To make the tradeoff visible, keep the 3% base payment rate and add another marginal rate only on income above $200,000 per tax return. The IRS distribution contains $4.185T above that threshold.

Extra rate = (budget − $359.3B) ÷ $4.185T

These are coverage payments in addition to existing taxes, unless laws and financing arrangements change. The example leaves $65,000 filers at $100/month, but larger budgets require substantial payments at higher incomes. A voluntary fund also cannot assume those members will all join and remain. The table assumes full participation and collection; an operating plan would also need to test lower participation.

Other designs can share the cost differently while keeping total receipts in balance with the care budget. A final individual model needs citizen-level age and income data, family-income treatment, and explicit affordability rules.

6. International evidence: much lower costs are real

2023 WHO Global Health Expenditure Database via World Bank WDI. Total spending includes public and private financing. PPP international dollars adjust for general purchasing power; they are not nominal U.S. dollars available to a fund. Out-of-pocket excludes taxes and insurance premiums. These columns measure different things and should not be subtracted. Total spending definition · Out-of-pocket definition.

Several countries deliver care for much less than the United States. Their results are evidence that the U.S. spending level is not inevitable. They are not proof that U.S. wages, service capacity and the fund’s broader benefits can be purchased for $100 per person monthly. A small bill at the doctor excludes the taxes and compulsory contributions financing that system.

Open the full country comparison

7. Build a fund members can count on

Required member revenue = care at negotiated prices + added use/benefits + fund operations + reserve addition + transition costs − committed outside funding

This analysis assumes no automatic employer payments, tax redirection or transfer of Medicare/Medicaid money. Those are not revenues available to a private fund merely because someone enrolls.

• Care prices: obtain procedure-level utilization and contracted prices, including geographic and age differences. Use cost reports to test provider viability rather than assuming current prices equal necessary costs.
• Benefits and access: price additional dental, vision, fertility, mental-health and long-term care, plus care currently deferred because of cost. Do not count unpaid family caregiving as a free substitute for promised paid care.
• Operations: budget claims, eligibility, drug procurement, logistics, legal advocacy, fraud controls and staff explicitly.
• Reserves: distinguish a one-time target balance from annual replenishment. Do not charge the full reserve target every year.
• Funding: calibrate the individual age/income formula to actual eligible members. Age weights redistribute the budget; they do not create savings. Do not use diagnoses or preexisting conditions to surcharge members.
• Start-up: test enrollment mix, early high-cost claims, capital and collection risk separately from a hypothetical nationwide steady state.

What this establishes: a sourced spending baseline, independently documented savings opportunities, and member-payment formulas that reconcile to specified budgets. It does not establish a viable 2026 fund premium. The next step is to turn those inputs into negotiated care agreements and a validated member funding model.

Follow every calculation

Download inputs, outputs and formulas (JSON) · Reproduction script · Original CMS workbook archive · Original IRS workbook

The script reads the source tables and tests budget/revenue reconciliation. Thresholds align with IRS bracket boundaries, so it does not estimate income using bracket midpoints. All money in the IRS source is multiplied by 1,000 as specified in its header. Component rounding is retained.

Prepared October 16, 2026. Historical analysis in the dollars of each stated year. No inflation escalation to 2026 or actuarial certification is claimed.