Beyond Reform: The Updated Appendix
Toward a Recommended Model — Rewritten After a Full Evidence Review
The appendix to Beyond Reform used to end with a specific destination: a public insurance core modeled on Canada, Taiwan, or Japan. Before rewriting it, I commissioned a rigorous, arm's-length review of the actual research literature — not a survey of arguments, but a genuine attempt to see what the evidence says when you strip away which side is saying it. It changed the shape of my answer more than I expected going in.
Why this appendix looks different than it used to
The earlier version of this appendix proposed a specific destination: a public insurance core modeled on Canada, Taiwan, or Japan, with a bounded private market layered on top in the manner of Australia. It was a reasonable proposal, built on the intuition that runs through the rest of this book — that a system built to extract profit from sickness cannot be trusted to fix itself, and that the cleanest way to remove that incentive is to put one public payer in charge of the money.
That intuition is still largely right. But a rigorous, arm's-length evidence review changed my confidence in single payer, specifically, as the mechanism that gets us out — not the conclusion that the current system is failing on cost and access; the evidence for that is overwhelming and gets stronger every year.
“The evidence is very strong that the two things actually wrecking American health care are prices and administrative complexity, not how many payers there are.”
It is much weaker — genuinely, legitimately contested among researchers with no stake in the political fight — on whether collapsing to one national payer, by itself, is what fixes those two things, or whether we can fix them a different way, with less risk, and with a system that has already shown it can survive contact with American politics. So this appendix proposes a model built around what the evidence says works, sequenced to manage the one risk the evidence says we have most badly underestimated: the transition itself.
Four Findings
What the evidence actually shows
I won't repeat the full case here — it lives in the research review that sits behind this book. But four findings from that review drive everything that follows, and they don't line up neatly with either side's usual talking points.
First: America's cost problem is a price problem, not a usage problem. Americans do not see the doctor more, spend more nights in the hospital, or get more surgeries than people in other rich countries — in several categories we use less care than they do. We pay far more for each unit of it.
This has been shown independently, using different data and different research teams, going back more than twenty years, and it has not stopped being true. If a reform doesn't touch prices, it isn't touching the actual problem.
Second: our administrative overhead is real, large, and mostly self-inflicted — but not entirely a function of having many payers. The most careful non-partisan estimate puts the cost of simply running the American system at roughly eight cents of every health-care dollar, against roughly three cents in other wealthy countries.
What surprised me is the fact sitting right next to it: Germany and the Netherlands, which both keep dozens of competing private insurers, run administrative costs far below ours — not by eliminating multiple payers, but by forcing every one of those payers to use the same claim forms, the same billing rules, and the same enrollment system. Multiple payers is not, by itself, what's expensive. Multiple sets of rules is.
Third: the case that a single national payer would, by itself, lower total health spending is real but genuinely unsettled. This was the hardest finding to sit with, because it cuts against the argument I'd been making.
The Congressional Budget Office — an institution with no side in this fight — modeled five different honest versions of a single-payer system and found that, depending on just two design choices (how much less doctors and hospitals get paid, and how much people's health-care use goes up once care is free at the point of service), the same idea could either save the country several hundred billion dollars a year or cost it a comparable amount more. Two research institutions on opposite ends of the political spectrum, modeling a generous Medicare-for-All-style plan, landed within a few percent of each other on how much it would raise the federal budget — a genuinely striking agreement — but that number is the size of the bill moved onto the government's books, not proof that total national spending, public and private combined, would go down.
Fourth: the part of single payer's promise the evidence supports most strongly isn't really about total spending at all — it's about who gets left out. Nearly half of lower- and middle-income Americans say they've skipped care they needed because of the cost.
Taiwan's move to national health insurance in 1995 shows this cleanly — the specific category of deaths that good medical access should prevent fell sharply right when coverage arrived, while deaths from causes medicine can't touch didn't move at all. That's about as close to a controlled experiment as this field gets, and it says the access problem is fixable. It does not, on its own, say that only one specific financing structure can fix it.
None of this makes the current American system defensible — it remains the most expensive and, on access and equity specifically, one of the worst-performing systems among wealthy nations. What it does is redirect where the fix has to concentrate its force, and it argues for getting the sequencing right rather than betting the entire reform on a single, mostly untested, high-risk transition.
The design principles this model is built on
Rather than start from “which country's system should we copy,” the recommended model below starts from the specific mechanisms the evidence shows actually work, and asks how much of American health care can be rebuilt around them without taking on risk the evidence can't yet justify.
- Regulate prices directly, rather than hoping competition will do it. Maryland is the only U.S. state where every payer, public and private, pays hospitals from the same regulated budget — and it has measurably slowed cost growth without anyone losing their existing insurance. This is the single clearest, most transferable lesson in the entire evidence review.
- Standardize the paperwork before — or instead of — eliminating the payers. If Germany and the Netherlands can run lean administratively with many insurers, the number of payers is the wrong target. The right target is the number of different rulebooks.
- Regulate drug prices the way every other wealthy country already does. Medicare won limited negotiating power for the first time in 2022. The evidence review found no serious argument, from either side, that extending real negotiating power would fail to bring brand-name drug prices down substantially.
- Close the coverage gap with a public plan built for the people the current system fails, not a replacement for the coverage that currently works for most people.
- Treat the transition itself as the main risk to be managed, not an afterthought to a spreadsheet. Vermont's own single-payer plan collapsed in 2014 not because voters rejected it, but because the state's own finance office found the promised savings weren't showing up even on paper.
The Recommended Model
A Public Core With Universal Rate Rails
Putting these principles together, here is what I now believe is the most defensible path — not because it is the boldest option, but because it is the one most directly supported by what the evidence actually shows works, and least dependent on assumptions no one has tested.
- A national all-payer rate system for hospitals and physicians. Take Maryland's model — one regulated payment schedule that every payer in the state uses, public or private — and apply it nationally. This is the single reform the evidence supports most strongly and unambiguously, because it is already running successfully inside the United States, not just abroad.
- A National Drug Pricing Board with real negotiating authority. Extend the negotiating power Medicare won in 2022 to cover all drugs, for all payers, using reference pricing against what other wealthy countries actually pay — not a voluntary ceiling, a binding one.
- A single national billing and eligibility standard, mandatory for every payer. One claims format. One set of prior-authorization rules, sharply narrowed in scope. One eligibility-verification system, modeled directly on the German and Dutch experience: keep multiple payers, but let none of them compete by making the paperwork more profitable to fight than to pay.
- A public plan — call it American Care — that automatically covers everyone the current system currently fails. Every currently uninsured person, every Medicaid recipient, and every ACA marketplace enrollee moves into one federally run plan, funded the way Medicare is funded, with zero cost-sharing below a defined income threshold. This is, in effect, single payer for the people single payer would help most — achieved without asking the roughly six in ten Americans currently covered through an employer to give up that coverage on a legislated deadline.
- Employer coverage and Medicare stay as they are — for now — but inside the same rate and billing system. Nothing in this model requires anyone with a job-based plan or Medicare coverage they're satisfied with to change insurers. What changes is that their insurer now pays providers the same regulated rate as everyone else, and can no longer compete by finding new ways to deny or delay a claim.
- A built-in public option, so the system can grow toward more public coverage if — and only if — it earns that expansion. Once American Care is running and its costs and outcomes are visible, any employer or individual should have the right to buy into it instead of a private plan, at a price set to reflect its real cost. The system consolidates over time based on demonstrated performance rather than a single legislative bet.
Who pays, and how much changes for you
Any honest reform proposal owes readers a plain answer to “what does this cost me,” so here is mine, stated as directly as the evidence allows.
American Care would be financed the way Medicare already is: a dedicated payroll contribution, supplemented by general federal revenue, replacing the current patchwork of Medicaid's federal–state financing and the ACA's subsidy structure. Because the population it covers is currently either uninsured (shifting the cost of their care onto emergency rooms, higher premiums for everyone else, and hospital bad-debt writeoffs) or under-covered on plans that already run substantially on public money, the net new federal cost of covering them is real but far smaller than the cost of a Medicare-for-All plan that also absorbs the roughly 155 million Americans currently covered through an employer.
The most rigorous financing-options analysis I found — produced by a fiscally conservative, deficit-focused organization with no reason to flatter this kind of proposal — concluded that most realistic ways of financing a large coverage expansion are more progressive than the premiums and out-of-pocket costs they would replace, meaning the households paying the most today are disproportionately the same households who would see the largest net benefit.
Employers keeping their current plans would see real, near-term relief for a different reason: once every payer is paying providers from the same regulated rate schedule, the wildly inflated prices employer plans currently negotiate — often 50% or more above what Medicare pays for the identical service — come down toward that same regulated rate. Hospitals and physicians who currently rely on privately insured patients paying above-cost rates to subsidize the below-cost rates they accept from Medicaid and the uninsured would see that specific cross-subsidy disappear — which is precisely why the rate schedule itself, and how fast it phases in, is the detail this whole model lives or dies on.
Why not go straight to single payer
I want to be honest about what this model gives up. The earlier version of this appendix was right that a single, unified public payer would be simpler, in principle, than the six-part structure above. Simplicity is a real virtue and I am not pretending otherwise.
But the evidence review's most important, and most uncomfortable, finding is that the single biggest source of uncertainty in this entire debate isn't whether single payer would work once it existed — it's whether the country could get there without the transition itself causing serious harm. Every credible cost model treats the finished system as the object of study; almost none of them seriously model the implementation itself: retraining or laying off a million-plus insurance-industry workforce, building new national claims infrastructure, and managing a payment shift of a scale the federal government has never previously attempted.
Vermont's experience — a small, willing state, with a supportive legislature, discovering at the planning stage that the savings its own study promised weren't materializing — is the only real-world data point we have on what that process actually looks like, and it isn't reassuring. California has tried and failed to pass even a state-level single-payer bill three times since 2022, most recently in 2026, for reasons that had less to do with the merits than with the sheer difficulty of financing and implementing a switch of this size inside one state's budget.
A national conversion faces a different, larger version of the same problem, magnified by the fact that roughly half the country currently gets coverage through an employer. The recommended model above deliberately avoids that cliff edge. It captures the price-regulation and administrative-standardization benefits the evidence supports most strongly, builds a genuine public single-payer core for the population that needs it most urgently, and leaves the door open — deliberately, structurally — to further consolidation if the early results justify it.
What this model does not solve
No model built from an honest reading of the evidence should claim to solve everything. This model does not resolve how aggressively the national rate schedule should pay physicians relative to hospitals — a fight every country with administered pricing has had internally and none has fully settled. It does not resolve how fast drug-price negotiation can be extended without disrupting investment in new treatments. It does not, by itself, fix the large share of America's health disadvantage that traces to poverty, violence, diet, and addiction rather than to the insurance system at all — no financing reform does. And it does not eliminate the risk that a newly covered population, no longer skipping care for cost reasons, will strain a health-care workforce already stretched thin in exactly the primary-care specialties this population needs most.
What it offers instead is a sequence: fix the prices, standardize the paperwork, cover the people currently being failed, leave the door open to more. It is a narrower promise than “Medicare for All by a date certain,” and it is the more honest one.
The rest of the argument — the six nations, the design principles, and why the honest answer is a new foundation rather than another repair — is in the book this appendix belongs to.
This appendix was rewritten from a rigorous, arm's-length evidence review of the peer-reviewed and government literature comparing U.S. healthcare financing with universal-coverage alternatives. Content current through August 2026.