Research Guide · Alternatives
What Should Replace American Healthcare?
If incremental reform keeps being absorbed by the financing structure it was meant to change, the question worth asking isn't which new rule to add next — it's what a different design would look like. Not a slogan. A specific answer to specific design questions: who finances it, who administers it, how providers get paid, and what tradeoffs come with each choice.
The design questions any replacement has to answer
Every healthcare financing system, in every country, answers the same set of design questions differently. Financing: is care paid for through a single public pool, multiple competing insurers, or some blend? Universality: is coverage automatic and continuous, or contingent on employment, income, or enrollment periods? Administrative simplicity: how much of every dollar goes to billing and claims versus care — a gap the U.S. currently pays roughly $1,055 per person for, against about $245 in comparable countries? Cost control: who has the leverage to negotiate prices, the way the VA does for drugs at roughly 54% less than Medicare pays? Access and equity: does the design close gaps in who gets care, or widen them? Accountability: who is answerable when the system fails a patient?
Every peer nation examined in Beyond Reform answers these questions differently from the U.S. and from each other — there is no single "socialized medicine" model, only a range of designs that all outperform the current American system on cost and outcomes, each with its own tradeoffs.
Three proposals examined on this site
Beyond Reform is the design study: what would American healthcare financing look like if it were built today, on a blank sheet of paper, using the evidence from six other nations — not to copy any one of them, but to learn what their designs prove is possible.
Replace, Don't Reform makes the direct case for single-payer financing in the U.S. specifically — why the current multi-payer structure resists reform from within, and what a single-payer alternative would change.
One Card, One Cure takes the argument to a concrete, state-level proposal: the Washington Health Trust, a drafted bill for a single-payer system in one state, with no premiums, deductibles, or copays for covered care.
Read together, they move from the theoretical design question to a specific, existing legislative proposal — the closest thing on this site to a direct answer to "what should replace it."
The honest tradeoffs
No design is free of tradeoffs, and this site tries not to pretend otherwise. A single national negotiator has more leverage to control prices, but concentrates decision-making. Simplifying administration saves money but requires unwinding an insurance industry that currently employs millions of people. Faster, more universal access could increase near-term utilization even as it reduces long-term cost from delayed, worsened conditions. The evidence in Beyond Reform and the case in A Case for Single-Payer Healthcare engage these tradeoffs directly rather than assuming them away.
Explore the design question in full, or go straight to the specific proposals.
Every figure on this page traces to a primary source in the annotated bibliography.