AMERICA Act of 2026 — Integrated Draft v3

(Core‑CPI, Four‑Pillar Financing, National Health Budget & Capital Planning, Program Integrity/Equity, and Conforming Amendments)

A Bill to Establish a Hybrid Single-Payer Healthcare System in the United States

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE

This Act may be cited as the “AMERICA Act of 2026” (American Medical and Essential Rights to Inclusive Care Act).

SECTION 2. FINDINGS AND PURPOSE

(a) Findings

Congress finds the following:

The current U.S. healthcare system is fragmented, costly, and inefficient, with administrative overhead and insurer profits exceeding $30 billion annually in denied care and net income for major insurers as of 2024.
All Americans deserve access to essential healthcare services without financial ruin, regardless of employment, income, or pre‑existing conditions.
Single‑payer systems in peer nations demonstrate that universal coverage financed through broad‑based contributions, paired with cost controls, can achieve efficiency and equity.
Transitioning to universal coverage in the United States requires a hybrid approach that preserves existing provider networks while simplifying administration and ensuring budget discipline.
Oversight should be limited to funding and compliance, not clinical decision‑making by medical professionals.
Protecting the system’s integrity requires safeguards against political interference, including protection for dedicated healthcare funds.
Income‑based co‑pays may promote responsible utilization while maintaining affordability and equity.
Integration of mental health, dental, hearing, vision, and telemedicine services will strengthen outcomes, particularly for rural communities.
ERISA‑based employer self‑insurance fragments standards; a unified national approach enhances interstate commerce and consistency.
Healthcare is an instrument of interstate commerce, requiring national uniformity and regulatory authority under the Commerce Clause.

(b) Purpose

The purpose of this Act is to:

Establish a national Healthcare Trust Fund (HTF) as the single payer for essential services.
Preserve a hybrid design allowing supplemental private insurance and continued use of Health Savings Accounts (HSAs) for non‑essential services.
Align financing with scope by redirecting existing federal and employer health dollars into the HTF, while enforcing cost controls and core‑CPI‑linked growth limits.
Eliminate profit‑driven denials of essential care and simplify administration.
Promote equity through phased integration, anti‑fraud capability, and uniform national standards.

SECTION 3. DEFINITIONS

For purposes of this Act:

Healthcare Trust Fund (HTF). A dedicated federal fund administered by the Department of Health and Human Services (HHS) that pays qualified providers for essential services.
Essential Services. Medical services, procedures, and pharmaceuticals initially based on those covered under Medicare as of 2026, subject to biennial review by the Medical Advisory Committee (MAC), and explicitly including primary care, hospital and outpatient care, mental/behavioral health, basic dental (preventive, basic restorative, and medically necessary orthodontia for children and specified adult indications), hearing (including audiology and hearing aids), vision (including medically necessary lenses/frames), and reproductive and sexual health services covered under federal standards (including contraception; prenatal, maternity, and postpartum care; and management of pregnancy complications and other pregnancy‑related care), preempting conflicting state restrictions on HTF‑covered services and implemented consistent with USPSTF A/B recommendations and ACOG clinical guidance.
Long‑Term Services and Supports (LTSS). A covered category of Essential Services that includes Home‑ and Community‑Based Services (HCBS) and necessary institutional care when HCBS is not appropriate, encompassing personal care, respite, home modifications, adult day health, care coordination, caregiver training, durable medical equipment for ADLs, and other supports as defined by HHS with priority for HCBS‑first delivery.
Qualified Provider. Any licensed healthcare professional or facility in the United States participating in the HTF, including telemedicine providers.
Lawful Resident. An individual who is lawfully present in the United States under federal immigration law and meets residency standards defined by HHS; visitors are billed under Section 4(c).
Visitor. Any individual present in the United States who is not a Lawful Resident or citizen.
Adjusted Gross Income (AGI). As reported on the most recent federal tax return, with annual verification via Internal Revenue Service (IRS) data‑sharing.
Rural Area. Designated zip codes under United States Department of Agriculture (USDA) Rural‑Urban Continuum Codes (RUCC 4‑9) or successor HHS metric.
Health Savings Account (HSA). Tax‑advantaged accounts under Section 223 of the Internal Revenue Code for qualified medical expenses.
Core CPI. The Core Consumer Price Index (all items less food and energy) as published by the Bureau of Labor Statistics (BLS); used for payment updates, caps, and automatic fiscal adjusters under this Act.
Employer Maintenance of Effort (Employer MOE). A mandatory employer contribution to the HTF that replaces prior employer premium spending, calculated as a percentage of payroll or prior‑year employer health spend, as provided in Section 5.
Medicaid Maintenance of Effort (Medicaid MOE). Federal and state contributions to the HTF that maintain fiscal effort equivalent to pre‑Act Medicaid spending, as provided in Section 5.
Federal Poverty Line (FPL). The annually published HHS poverty guidelines used to determine contribution floors under this Act.
Veterans Health Administration (VA). The federal program furnishing care to eligible veterans.
TRICARE. The Department of Defense health care program for uniformed service members, retirees, and their families.
Indian Health Service (IHS). The federal program providing health services to American Indians and Alaska Natives.
Centers for Medicare & Medicaid Services (CMS). The HHS agency administering Medicare, Medicaid, and related programs.
Government Accountability Office (GAO). The legislative branch agency providing audits and evaluations for Congress.
Office of Inspector General (OIG). The HHS oversight office investigating fraud and abuse.
Administrative Procedure Act (APA). 5 U.S.C. § 551 et seq., governing federal administrative process and review.
National Institute of Standards and Technology (NIST). The federal standards body referenced for cybersecurity controls.
U.S. Preventive Services Task Force (USPSTF). The evidence‑review body whose A/B recommendations inform preventive coverage.
American College of Obstetricians and Gynecologists (ACOG). A clinical body whose guidelines inform reproductive and maternal health coverage.
Community Health & Equity Fund (CHEF). The program established in Section 13(e) for population‑health and equity initiatives.
Quality Incentive Program (QIP). The payment quality framework established in Section 5(k).
Patient‑Reported Outcome Measures (PROMs). Standardized instruments capturing patient‑reported health status used in the QIP.
Home‑ and Community‑Based Services (HCBS). A subset of LTSS delivered outside institutional settings with an HCBS‑first preference.
Graduate Medical Education (GME). Federally supported medical training positions.
National Health Portal (NHP). The secure federal portal described in Section 5(j)(2) providing records access, OOP tracking, dashboards, and telemedicine.
Affordable Care Act (ACA). The Patient Protection and Affordable Care Act, Pub. L. No. 111‑148, and related amendments.
Congressional Budget Office (CBO). The legislative branch fiscal scoring office.
Joint Economic Committee (JEC). The joint committee of Congress monitoring economic trends.
Social Determinants of Health (SDOH). Non‑medical factors influencing health outcomes used for equity and risk‑adjustment under this Act.
High Medical Complexity Beneficiary (HMCB). A beneficiary meeting HHS criteria for multi‑morbid conditions, high acuity, or rare diseases warranting supplemental affordability support.
Access Standard. Timeliness and availability requirements for appointments and services set under Section 5(l).
Shared‑Savings Arrangement (SSA). An arrangement under which a provider group may share in demonstrable savings against targets under Section 5(k)(7).
Transition Ombuds Office (TOO). The office established by Section 7(e) to resolve beneficiary transition issues and appeals.
Patient & Caregiver Advisory Board (PCAB). The board established by Section 18(d) to advise HHS and MAC.
Standardized Supplemental Plan (SSP). A standardized supplemental plan template (e.g., SSP‑Basic, SSP‑Enhanced) published by HHS under Section 4(b)(6).
Office of Management and Budget (OMB). The Executive Office that publishes federal standards including race/ethnicity classifications cited in Section 5(j).
Health Professional Shortage Area (HPSA). An area designated by HHS with shortages of primary medical, dental, or mental health providers.
Federal Employees Health Benefits (FEHB). The federal program providing health insurance to federal employees and retirees.
Children’s Health Insurance Program (CHIP). A joint federal–state program providing health coverage to eligible children.
Self‑Employment Contributions Act (SECA). The statute governing Social Security and Medicare taxes for the self‑employed.
Workers’ Compensation (WC). State systems providing medical and wage benefits for work‑related injuries and illnesses.
Certificate‑of‑Need (CON). A planning process for major capital expenditures requiring approval based on need.
Automation Dividend Health Contribution (ADHC). The employer obligation defined in Section 5(a)(5) for workforce displacements due to automation, AI, robotics, or outsourcing.

SECTION 4. ESTABLISHMENT OF UNIVERSAL COVERAGE

(a) Eligibility.

Every U.S. citizen and Lawful Resident shall be eligible for Essential Services under the HTF. Visitors are billed under Section 4(c). HHS shall promulgate residency standards (consistent with federal immigration law and substantial‑presence principles) to prevent medical tourism, while ensuring immediate coverage for emergencies, pregnancy‑related care, and communicable‑disease control.

(b) Hybrid System and Supplemental Market.

The HTF is the primary payer for Essential Services, replacing private insurance for those services.
Private insurers may offer supplemental coverage for non‑essential services and amenities; they may not deny or delay HTF‑covered services.
Employers and individuals transition over five years; low‑income participants receive refundable tax credits for supplemental coverage where appropriate.
VA, TRICARE, and IHS remain operational; beneficiaries may opt to integrate with HTF per agency agreements.
Preservation of HSAs. HSAs may be used for non‑essential services, co‑pays, or other qualified expenses; nothing in this Act restricts new or existing HSAs.
Required Minimum Benefits (Supplemental). Any supplemental plan offered in the United States shall, at minimum, cover: (A) dental (preventive and basic restorative); (B) adult vision hardware (lenses/frames annually as clinically appropriate); (C) hearing aids (at least every 3 years, or per clinical need); and (D) optional LTSS riders meeting HHS standards. Within 12 months, HHS shall publish Standardized Supplemental Plans (SSP‑Basic/SSP‑Enhanced) that meet or exceed these minima with transparent, comparable benefits and cost‑sharing.
Consumer Protections (Supplemental). Supplemental issuers shall provide: guaranteed issue, no pre‑existing condition exclusions, no rescissions, community rating within HHS age bands, anti‑discrimination protections consistent with federal civil‑rights laws, and standardized appeals. Each issuer must offer at least one SSP‑Basic option in every state where it operates.
Medically Complex Affordability Support. HHS shall establish Supplemental Affordability Credits for HMCBs to reduce premiums and cost‑sharing for supplemental benefits. Credits shall be targeted, means‑ and needs‑tested, and administered within HTF outlay caps not to exceed 0.2% of annual HTF outlays, indexed to Core CPI.

(c) Non‑Resident (Visitor) Billing.

Visitors shall be billed post‑service at HHS‑established fair market rates based on Medicare schedules plus 20% administrative fee; international collection agreements may be used.

(d) Patient Cost‑Sharing (Co‑Pays).

Low‑Income (≤ $75,000 AGI individual / $150,000 household). $0 for Essential Services except: ER $50; ambulance $50; hospital day $25 (max $500/yr for this category); Rx $10 or price if lower; specialist $25; imaging $25; mental health $25; vision visit $25 ($50 for basic lenses/bifocals/trifocals).
Mid‑Income ($75,001–$200,000). ER $100; ambulance $100; hospital day $50 (max $500/yr); primary care $20; Rx $20 or price if lower; specialist $50; imaging $50; labs $10 per order; mental health $50; vision $25 ($100 for basic lenses/bifocals/trifocals).
High‑Income (>$200,000). Co‑pays in paragraph (2) are doubled.
Very‑High‑Income (>$500,000). Co‑pays in paragraph (2) are tripled.
Annual OOP Cap. Total co‑pays are capped at 5% of AGI annually, tracked via the NHP; excess automatically refunded.
Administration and Hardship. Providers collect co‑pays; HHS may waive for hardship. HSAs may pay co‑pays.
Exemptions. Preventive care, vaccinations, pediatric services, and telemedicine overhead adjustments are exempt; telemedicine co‑pays mirror in‑person.
Appeals. Patients may appeal co‑pay determinations to the HHS Ombuds Office within 30 days; decisions are binding and judicially reviewable.

(e) Telemedicine Parity.

Telemedicine services are reimbursed at 80% of equivalent in‑person rates; platforms must meet federal cybersecurity standards.

SECTION 5. FINANCING, NATIONAL HEALTH BUDGET, AND COST CONTROL

(a) Four‑Pillar Financing (with SECA parity and anti‑avoidance).

To align revenue with scope and ensure fiscal balance, the HTF is financed through the following consolidated pillars:

AMERICA Act Payroll Contribution (W‑2).
(A) Employer portion (doubled). Employer marginal rates:
• Up to $200,000 AGI: 9.33% employer;
• $200,001–$500,000: 16% employer;
• $500,001–$1,000,000: 20% employer;
• Over $1,000,000: 24% employer.
(B) Employee portion. Employee marginal rates are capped at 9.5% and may not fall below 5% for individuals/households at or above 105% of FPL; those below 105% FPL owe 0%.
(C) Contributions apply to all wages and compensation with no upper cap.
Self‑Employed (SECA Parity) and Pass‑Through Anti‑Avoidance.
(A) SECA mirror. Self‑employment income is subject to combined employer+employee AMERICA Act rates equivalent to W‑2 at the applicable marginal brackets, with deductible employer‑equivalent portion as under SECA.
(B) Pass‑through avoidance. HHS and Treasury shall issue rules to treat reasonable compensation for S‑corporation and partnership owners as wage‑like for AMERICA Act contributions; schemes that convert labor income to distributions are disregarded.
(C) Non‑wage health contribution. For AGI above $400,000, net investment income and pass‑through distributions are subject to a 1.0% AMERICA Act non‑wage health contribution, indexed to Core CPI, with de minimis exemptions under $25,000.
Medicare Realignment.
(A) The Medicare Hospital Insurance (HI) payroll tax and the existing HI Trust Fund balance are consolidated into the HTF.
(B) Medicare Parts B and D general revenue contributions are redirected to the HTF, with beneficiary protections maintained.
Medicaid Maintenance of Effort (Medicaid MOE). Federal and state Medicaid funding streams are redirected to the HTF on a maintenance‑of‑effort basis equal to pre‑Act levels, with state contributions indexed to Core CPI and adjusted for enrollment.
Employer Maintenance of Effort (Employer MOE) and Automation Dividend Health Contribution (ADHC).
(A) Employer MOE. Employers shall remit the greater of: (i) 7.5% of payroll, or (ii) the employer’s inflation‑adjusted prior‑year spending on employee health benefits (premiums, HRA/HSA contributions, equivalently valued self‑insurance), net of employee contributions. Credits avoid double‑payment against employer AMERICA Act payroll liability.
(B) ADHC (workforce displacement). For any Covered Workforce Displacement Event—defined as layoffs or position eliminations caused in material part by AI, automation, robotics, outsourcing, or offshoring—the employer shall continue to remit the employer‑portion of AMERICA Act payroll contribution and Employer MOE for each displaced worker for 5 years after separation, based on the worker’s final‑year wage indexed to Core CPI, unless: (i) the employer certifies insolvency or closure; (ii) the worker attains new coverage via employment or self‑employment (credits apply); or (iii) the employer offers and the worker accepts equivalent employment. Small‑employer safe harbor may apply for employers with <25 employees (HHS/Treasury rule). Evasion via misclassification is prohibited and subject to penalties under Section 8.

(b) Exclusivity; Anti‑duplication.

Amounts redirected under this Section replace duplicative outlays for Essential Services under prior programs. No other federal agency may pay for Essential Services outside the HTF, except as authorized for VA, TRICARE, and IHS.

(c) Payment Updates; Core‑CPI Indexation.

Reimbursement Index. Maximum reimbursement rates for HTF‑covered services are tied to 100% of current Medicare schedules, indexed annually to Core CPI.
Automatic Adjusters. All statutory caps, thresholds, penalties, and administrative limits under this Act are indexed to Core CPI unless otherwise specified.

(d) Hospital Global Budgets; Site‑Neutral Payment.

All‑Payer Global Budgets. Beginning in plan year 2, hospitals shall be paid under global budgets established by HHS (or approved state rate‑setting entities). Aggregate budget growth shall not exceed: (A) Core CPI + 2.5 percentage points in Plan Years 1–2 (transition and infrastructure build); (B) Core CPI + 1.5 percentage points in Plan Years 3–5 (initial implementation); (C) Core CPI + 1.0 percentage points in Plan Years 6–10 (maturing system); (D) Core CPI + 0.5 percentage points in Plan Year 11 and thereafter (long‑run target); unless waived for population need or declared emergencies. The Secretary shall publish a Pathway to Long‑Run Discipline Report every two years beginning in Plan Year 3, assessing whether the step‑down schedule remains on track and recommending adjustments to Congress if structural factors (workforce costs, demographic demand, or capital needs) indicate the schedule requires revision. If the HTF reserve threshold in Section 5(g)(3) is met for two consecutive years during Plan Years 1–5, the Secretary may, with MAC concurrence, advance the next phase of the step‑down schedule by up to one year, subject to joint resolution of disapproval.
Site‑Neutrality & Facility Fees. For routine outpatient services (including imaging, labs, and telehealth), the HTF shall pay site‑neutral rates. Facility fees for off‑campus or non‑hospital settings are prohibited unless HHS determines clear cost justification.
Primary‑Care & Behavioral Health Models. HHS may implement risk‑adjusted capitation for primary care and behavioral health with retrospective outlier review.

(e) National Health Budget and Capital Budget Board.

National Health Budget. Each fiscal year, HHS shall publish a National Health Budget for HTF operations and capital, consistent with this Section and indexed to Core CPI.
Capital Budget Board (CBB). A federal Capital Budget Board shall approve major capital expenditures and service‑line expansions exceeding thresholds set by rule, using CON‑like criteria weighted by HPSA status, RUCC, equity impact, and demonstrated community need.
Public Dashboard. HHS shall maintain a public capital dashboard mapping approved and denied projects, rationales, and geographic equity metrics.
Deeming & Federal–State Role. States may operate aligned capital review entities approved by HHS; federal standards remain controlling.
No Volume Gaming. Capital approvals shall not be tied to volume‑based payment projections; global budgets shall be adjusted only for approved capacity and population need.

(f) Administrative Cap.

HTF administrative expenditures shall not exceed 7% of total HTF outlays.

(g) Sustainability Modeling and Triggers.

HHS shall annually model five‑year revenues and outlays and publish quarterly reserve metrics for the HTF.
If projected deficits exceed 3% of outlays, automatic, temporary adjustments shall increase AMERICA Act payroll rates by up to 0.5 percentage points across brackets and/or raise Employer MOE by up to 0.5 percentage points of payroll, subject to a joint resolution of disapproval.
If cumulative reserves exceed two months of outlays for two consecutive years, the Secretary may reduce AMERICA Act payroll rates or Employer MOE by up to 0.5 percentage points, consistent with actuarial balance.
Transition Reserve Floor. During Plan Years 1 through 5, HTF operating reserves shall not fall below one month of projected outlays. Breach of this floor shall immediately trigger the automatic adjusters in paragraph (2) without waiting for the projected-deficit threshold, and the Secretary shall notify Congress within 5 business days. Monthly reserve levels shall be published on the NHP during Plan Years 1 through 3; weekly if reserves fall below the one-month floor.

(h) Pharmaceutical Pricing.

Generics First. HTF prioritizes generics when clinically appropriate.
HTF‑Wide Negotiation. HHS shall negotiate cost‑plus and class‑based prices and may use international reference pricing for launches.
No Coverage Gaps. The HTF provides continuous essential drug coverage without donut holes; beneficiary OOP counts toward the 5%‑of‑AGI cap.

(i) Fraud & National Health Portal.

AI‑Driven Fraud Detection with annual bias/accuracy audits; human review required for adverse actions.
National Health Portal (NHP). The NHP provides OOP tracking, longitudinal health records, standardized stratified reporting, public dashboards (including access metrics), and telemedicine. Stratification shall at minimum follow OMB race/ethnicity standards, standardized disability reporting per HHS rule, and rural/urban classification using USDA RUCC categories.
HIPAA Expansions. Interoperability mandates, patient data ownership, 24‑hour breach notices, protections for de‑identified data, and NIST‑aligned cybersecurity.

(k) Quality Incentive Program (QIP).

Establishment. Beginning Plan Year 2, the Secretary shall operate a QIP that applies to hospitals, primary care, behavioral health, and multi‑specialty groups.
Withhold/Bonus. The HTF shall withhold 1.5% of applicable payments subject to QIP; entities may earn back the withhold and up to an additional 1.5% bonus based on performance.
Measures. At a minimum: avoidable readmissions; access timeliness; adherence to evidence‑based care; PROMs; equity‑stratified outcomes; behavioral‑health integration; and preventive uptake.
Risk Adjustment & Methodology. HHS shall apply appropriate clinical and social risk adjustment; measure specifications and methodology (including case‑mix and SDOH factors) shall be published for notice‑and‑comment 90 days before each performance year.
Public Reporting Cadence. Facility and group‑level QIP results shall be posted in machine‑readable format on the NHP by March 31 following the close of each performance year, and archived for longitudinal comparison.
Budget Neutrality. QIP operates within existing HTF outlays and does not increase total payments above caps.
Shared‑Savings for Multi‑Specialty Groups. HHS shall create an optional Shared‑Savings Arrangement (SSA) under which qualifying multi‑specialty groups may share in measurable savings against risk‑adjusted targets, contingent on meeting QIP quality thresholds and beneficiary protections.

(l) Access Standards and Corrective Actions.

National Minimums.
(A) Primary care (routine): appointment within 14 calendar days; urgent within 48 hours.
(B) Specialty (non‑urgent): appointment within 30 calendar days.
(C) Mental/Behavioral health (non‑urgent): appointment within 10 business days; crisis within 24 hours.
(D) Telemedicine: same as in‑person standard.
Monitoring & Dashboards. HHS shall publish quarterly, state‑stratified access dashboards on the NHP; the first dashboard shall go live no later than the end of Year 1 and thereafter be maintained on a quarterly cadence.
Corrective Action. Entities failing standards for two consecutive quarters shall: (A) submit a Corrective Action Plan; (B) be subject to a targeted performance at‑risk amount up to 1% of HTF payments until remediation; and (C) where capacity is binding, receive temporary capacity grants (e.g., extended hours, locum tenens, telehealth pods).
Persistent Failure. After 12 months without remediation, HHS may: (A) impose financial penalties up to $100,000 per instance; (B) reallocate GME slots and targeted workforce incentives to shortage areas; and (C) authorize patient travel vouchers for necessary out‑of‑area care at HTF expense.
Non‑Preemption of Higher State Standards. States may exceed these standards.

SECTION 6. ADMINISTRATION AND OVERSIGHT

(a) Role of HHS; Terms of Participation.

HHS shall administer payments, verify services, combat fraud using AI‑assisted detection with human oversight, and manage IRS data integration for income verification; HHS may not direct clinical decisions.
Provider Participation & Contracts. As a condition of participation, any provider or facility that is Medicare‑certified or receives federal funds (including Medicare, Medicaid, VA/TRICARE/IHS contracts, GME, federal grants, or capital approvals under Section 5(e)) shall participate in the HTF and accept HTF terms of participation, including data reporting, audits, and compliance with Sections 5 and 8. Failure to participate renders the entity ineligible for such federal funds.
Prohibition on Unilateral Changes. The Secretary may not unilaterally change covered benefits, eligibility, reimbursement rates, or co‑pays. Changes require MAC approval and a joint resolution of Congress within 90 days. Civil penalties up to $1,000,000 per violation apply.
Prevention of Executive Interference. No executive action may alter this Act absent statute; unlawful actions are null and void and subject to expedited judicial review under the APA.
Automatic Injunction Mechanism. If an executive official attempts to impair the HTF, a petition by 10 or more states shall trigger an automatic preliminary injunction pending expedited review by the Supreme Court.
Equity Impact Assessments. HHS shall conduct and publish Equity Impact Assessments for material coverage, pricing, or administrative changes, including MAC recommendations, with stratified projections and mitigation plans.

(b) Payment in Full; Balance‑Billing Prohibition.

Payment made by the HTF (plus any applicable co‑pay) shall constitute payment in full for Essential Services. Balance‑billing is prohibited for HTF‑covered services. Violations are subject to civil penalties, restitution, and potential exclusion from participation.

(c) Clinical Decision‑Making and Patient Choice.

Medical necessity, triage, and scheduling are determined by qualified providers.
Patients may seek care from any qualified provider nationwide without prior authorization or network restrictions.
Enforcement of Patient Choice. Unauthorized restrictions are subject to civil penalties up to $100,000 per violation, with whistleblower protections and GAO oversight.

(d) Drug Supply Assurance; Public Manufacturing & Compulsory Licensing.

If a manufacturer refuses to offer reasonable terms under Section 5(h) or engages in anticompetitive supply restriction, the Secretary may, after notice and hearing: (1) authorize public manufacturing or contract manufacturing of the product; (2) suspend or narrow exclusivity through compulsory licensing consistent with federal law (including Bayh‑Dole march‑in authority and 28 U.S.C. § 1498); and (3) set interim fair pricing pending resolution. Judicial review shall be expedited.

(e) Medical Advisory Committee (MAC).

Composition. Two physicians per state (100 total), selected by lottery; two‑year non‑renewable terms.
Duties. Biennial review of Essential Services and co‑pay applicability; recommendations require a two‑thirds vote and are binding. Congress may override a MAC recommendation only by concurrent resolution passed by a two‑thirds vote of both chambers, accompanied by written findings — adopted as part of the resolution — stating with specificity why the recommendation is contrary to the public welfare. A concurrent resolution that lacks such findings or fails to achieve a two‑thirds vote in either chamber is without legal effect and does not suspend the binding recommendation.
PCAB Liaisons. Two non‑voting PCAB liaisons shall attend MAC meetings and may offer public comment and written recommendations for the record.

SECTION 7. TRANSITION AND IMPLEMENTATION

(a) Timeline and Phase Gates.

Year 1. Establish HTF, MAC lottery, data pipelines (IRS, CMS, states), NHP, and payment operations; publish initial site‑neutral schedule; pilot hospital global budgets.
Year 2. Consolidate Medicare HI and Parts B/D flows into HTF; launch national global budgets under the phased growth cap in Section 5(d)(1); begin Employer MOE at 5.0% of payroll.
Years 3–4. Raise Employer MOE to 6.25% of payroll in Year 3 and 7.5% of payroll in Year 4; complete Medicaid MOE transition for all states; phase in mental health, DHV, and LTSS coverage.
Years 2–5. Phase‑out private insurance for Essential Services; fully implement site‑neutral payments and facility‑fee restrictions.
Pre‑Implementation Certification. Not later than 90 days before each major phase in paragraphs (2)–(4), the Secretary shall obtain: (A) a CBO cost estimate showing no increase in the unified federal deficit over the budget window attributable to the phase; and (B) an independent actuarial certification that the HTF remains in actuarial balance under the Core‑CPI growth caps.

(a)(6) Reform Savings Milestones.

The Secretary shall certify achievement of the following annual savings targets, with remediation plans required if any target is missed by more than 15 percent in a given plan year: (A) Administrative simplification: $30B by end of Plan Year 1; $90B by end of Plan Year 3; $150B by end of Plan Year 5. (B) Drug pricing (combined base and class‑based negotiation): $30B by end of Plan Year 2; $80B by end of Plan Year 4. (C) Site‑neutral payments: Rulemaking complete by end of Plan Year 1; $20B in savings by end of Plan Year 3 (subject to judicial resolution); $60B by end of Plan Year 5. (D) Global hospital budgets: Pilot in not fewer than 5 states by end of Plan Year 1; national rollout by Plan Year 2 with $30B in savings; $90B by end of Plan Year 5. (E) Reporting. HHS shall publish an annual Reform Savings Progress Report on the NHP comparing realized savings against these milestones. Where savings exceed milestones in a given category, the Secretary may apply the surplus to accelerate step‑down of the growth cap under Section 5(d)(1)(D).

(b) Impact on Stakeholders.

Insurers pivot to supplemental markets and administrative services.
Providers gain stable cash flow with simpler billing and defined growth paths.
Patients gain access, free choice of qualified providers, and income‑scaled affordability; HSAs remain for extras.

(c) Reporting.

HHS shall report annually on coverage, wait times (<30 days for non‑urgent care), equity metrics, patient satisfaction, and financial balance versus baselines. CBO and JEC reporting under Section 16(a) shall be timed to precede planned phase gates by at least 60 days.

(d) Transition Continuity‑of‑Care Guarantees.

12‑Month Protection. Beneficiaries in active treatment (including oncology, pregnancy, major surgery, dialysis, transplant workups, long‑acting injectables, complex behavioral care, and HCBS‑dependent LTSS) may continue with their current providers for 12 months, regardless of HTF participation status, at HTF rates.
No New Prior Authorization. Ongoing regimens shall not require new prior authorization during the continuity period.
Notice & Navigation. HHS shall issue standardized beneficiary notices, fund navigation hotlines, and provide expedited appeals (decision within 72 hours) for transition disruptions.
Data Handoffs. Providers shall promptly transmit records to successor providers with patient consent under HIPAA expansions.

(e) Transition Ombuds Office (TOO).

Establishment. A TOO is established within HHS and accessible through the NHP to resolve beneficiary transition issues, continuity disputes, and appeals.
Authority. The TOO may issue binding determinations on transition disputes subject to judicial review and shall publish anonymized quarterly reports of issues and resolutions.

(f) Initial HTF Capitalization.

HI Trust Fund Transfer. Upon HTF establishment, the Secretary of the Treasury shall transfer the full balance of the Medicare Hospital Insurance Trust Fund to the HTF as initial operating reserves, consistent with the consolidation in Section 5(a)(3)(A). Such balance shall be recorded on the HTF balance sheet and reported in the first annual HTF financial statement.
Startup Appropriation Authority. There is hereby authorized to be appropriated to the HTF, for Plan Year 1 only, such sums as necessary to fund administrative infrastructure, National Health Portal buildout, MAC operations, beneficiary enrollment systems, and provider onboarding, not to exceed $50,000,000,000. Amounts appropriated under this paragraph shall be repaid to the General Fund from HTF operating surpluses by the end of Plan Year 4, with interest at the 10-year Treasury rate.
Reserve Reporting. HHS shall publish monthly HTF reserve levels during Plan Years 1 through 3 on the NHP, transitioning to quarterly thereafter. If reserves fall below one month of projected outlays at any time during Plan Years 1 through 5, reporting frequency shall revert to weekly until the floor is restored.

(g) Medicare Advantage (Part C) and Medigap Transition.

Plan Wind‑Down. CMS shall not enter into or renew Medicare Advantage contracts under 42 U.S.C. § 1395w‑27 for plan years beginning on or after Plan Year 3. Existing contracts shall honor their current plan year and shall not be extended.
Automatic Enrollment. Not later than 180 days before the Plan Year 3 effective date, CMS shall: (A) notify each Medicare Advantage enrollee in writing of their automatic enrollment in HTF Essential Services coverage; (B) provide enrollment assistance, supplemental plan options meeting Section 4(b) standards, and Transition Ombuds contact information; and (C) ensure seamless assignment of a primary care team consistent with Section 5(k).
Supplemental Market Continuation. Medicare Advantage organizations may continue to offer supplemental coverage for non‑Essential Services consistent with Section 4(b), including dental upgrades, vision hardware, fitness benefits, and transportation. Such organizations shall not offer or market coverage duplicative of Essential Services covered by the HTF and shall comply with Standardized Supplemental Plan (SSP) standards published under Section 4(b)(6).
Special Needs Plans (SNPs). (A) Dual‑Eligible SNPs (D‑SNPs) shall transition Essential Services coverage to the HTF and may continue as supplemental care‑coordination plans for Medicaid‑eligible individuals under joint HHS/CMS transition rules published no later than the end of Plan Year 1. (B) Chronic Condition SNPs (C‑SNPs) shall continue through Plan Year 4 to protect continuity for enrollees with qualifying chronic conditions; Essential Services coverage shall transfer to the HTF upon plan‑year expiration and supplemental care management may continue under Section 4(b). (C) Institutional SNPs (I‑SNPs) shall transition consistent with the LTSS framework under Section 20.
Capitation Wind‑Down. CMS shall cease risk‑adjusted capitation payments for Essential Services to Medicare Advantage organizations as HTF coverage takes effect for each beneficiary. CMS shall publish the final capitation wind‑down methodology no later than 12 months before the Plan Year 3 effective date.
Extra Benefits Classification. Within 180 days of enactment, HHS shall publish guidance classifying current Medicare Advantage extra benefits (including over‑the‑counter allowances, transportation, fitness, and meal programs) as essential or supplemental for purposes of this Act. Benefits classified as non‑essential are eligible for supplemental plan offerings under Section 4(b).
Medigap Alignment. Medicare Supplement (Medigap) policies issued or renewed after the effective date of this Act shall comply with the supplemental plan standards of Section 4(b), including Required Minimum Benefits under Section 4(b)(6). Existing policyholders are grandfathered through their current policy year; policies shall conform to Section 4(b) upon first renewal after the effective date.
Transition Plan. Within 180 days of enactment, CMS shall publish a Medicare Advantage Transition Plan covering: (A) beneficiary notification and enrollment assistance timelines; (B) plan wind‑down and contract termination procedures; (C) network adequacy standards for HTF during the transition period, including rural and SNP populations; (D) workforce transition support for Medicare Advantage plan employees; and (E) coordination with state Medicaid agencies for dual‑eligible transitions.
Continuity of Care. Medicare Advantage enrollees in active treatment as described in Section 7(d)(1) retain all continuity‑of‑care protections for a minimum of 12 months following their effective HTF enrollment date.

SECTION 8. ENFORCEMENT AND PENALTIES

(a) Fraud Definitions and Penalties.

Fraud includes intentional deception or omission in claims, service provision, or co‑pay collection that causes improper HTF payments.
Provider Fraud. Fines up to $2.5M and ≥180 days imprisonment for the first occurrence; up to $5M and ≥1 year imprisonment plus license revocation for the second; enhanced penalties thereafter.
Patient Fraud. Fines up to $250k (first), $500k and ≥90 days (second), $1M and ≥1 year (subsequent).
Co‑Pay Evasion. Intentional evasion is fraud; non‑fraudulent missed co‑pays by citizens, Lawful Residents, or ITIN filers may be collected by the IRS through normal processes.

(b) Audits and Oversight.

GAO shall perform annual independent audits of HTF operations, payment accuracy, AI efficacy, and MAC decisions; HHS must implement recommendations within 180 days or explain to Congress.

(c) Additional Safeguards.

OIG enforces with a five‑year statute of limitations; negligent violations may incur civil penalties up to $500k per incident.

SECTION 9. SEVERABILITY

If any provision is held invalid, the remainder shall remain in effect. Co‑pay provisions are severable; if invalidated, default to $0 co‑pays for all until Congress acts.

SECTION 10. PREEMPTION, COORDINATION, AND CONFORMING AMENDMENTS

(a) Federal Preemption.

This Act preempts state laws that conflict with HTF operations under the Supremacy Clause (Article VI), including state insurance mandates, provider regulations, or benefit standards that duplicate or hinder federal uniformity in Essential Services. State restrictions that impede access to the essential reproductive and sexual health services referenced in Section 3(2) are preempted as applied to HTF‑covered services. State HSA rules remain where not conflicting.

(b) HTF Primary Payer; Third‑Party Recoveries.

The HTF is the primary payer for medical expenses related to injuries or illnesses covered by other insurance, including WC, auto/PIP, liability, and no‑fault. The HTF shall have subrogation and reimbursement rights to recover the reasonable value of services from third parties or their insurers; beneficiaries shall cooperate with recovery consistent with due process protections.

(c) Federal Programs (FEHB/CHIP/Exchanges/Medicare Advantage) Conforming.

FEHB Alignment. FEHB medical coverage for Essential Services shall transition to the HTF by the start of Year 3; FEHB may continue to offer supplemental benefits consistent with Section 4(b).
CHIP Coordination. CHIP medical benefits for Essential Services transition to the HTF by the start of Year 3; federal and state CHIP funding streams become part of Medicaid MOE to HTF.
ACA Exchanges Sunset. Qualified Health Plans offering Essential Services on exchanges shall sunset for plan years beginning Year 3; exchanges may continue as supplemental marketplaces.
Medicare Advantage (Part C) Sunset. Medicare Advantage contracts shall not be renewed for plan years beginning on or after Plan Year 3; Medicare Advantage organizations may offer supplemental plans consistent with Section 4(b). Full transition mechanics, Special Needs Plan treatment, capitation wind‑down, and Medigap alignment are governed by Section 7(g).

(d) Workers’ Compensation Coordination.

States shall coordinate WC medical benefits with the HTF. WC carriers shall reimburse the HTF for medical expenditures paid on compensable WC claims; disputes are resolved via federal standards with deference to state determinations of compensability.

(e) ERISA Conforming; No Duplicative Benefits.

No Duplicative Essential Benefits. Employee benefit plans governed by ERISA may not offer coverage duplicative of Essential Services covered by the HTF. Plans may offer supplemental benefits as defined in Section 4(b).
ERISA Sunset and Savings. To the extent ERISA previously preempted state regulation of employer health benefits, such preemption is sunset with respect to Essential Services; existing fiduciary and reporting obligations remain as to supplemental benefits.
Multiemployer Plans. Multiemployer funds shall transition Essential Services to the HTF and may continue as supplemental plans.

SECTION 11. CONSTITUTIONAL BASIS AND SAFEGUARDS

(a) Constitutional Basis.

This Act is enacted under the Commerce Clause (Article I, Section 8), as HTF regulates interstate economic activity in healthcare, a national market with multi‑state delivery and cross‑border impacts. Mechanisms such as MAC and injunctions are administrative procedures subject to judicial review, not delegations of legislative power.

(b) Proposed Constitutional Amendment.

“The funds of the Healthcare Trust Fund and Social Security Trust Fund shall be inviolate and used solely for their designated purposes. No law shall divert or borrow from these funds without ratification by three‑fourths of the states.”

SECTION 12. EFFECTIVE DATE

This Act takes effect 180 days after enactment. Funding mechanisms and co‑pay rules begin in FY 2027, with transition milestones per Section 7.

SECTION 13. WORKFORCE EXPANSION AND TRAINING INITIATIVE

(a) National Healthcare Workforce Expansion Plan. Within 12 months, HHS shall submit a national workforce plan that includes:

Expansion of medical, nursing, and allied‑health education via grants and loan forgiveness;
Prioritization of primary care, mental health, geriatrics, and rural disciplines;
A National Healthcare Corps with tuition forgiveness up to $250,000 for five‑year service in underserved areas;
Annual distribution reports to Congress.

(b) Training Infrastructure. Fund residencies and clinical training in shortage specialties.
(c) Telehealth Training. Establish national telemedicine certification for competency, privacy, and security.
(d) Pipeline Development. Grants to community colleges for allied roles, prioritizing rural/underrepresented populations.

SECTION 14. PUBLIC HEALTH INTEGRATION AND PREVENTION

(a) Preventive Care. Preventive services are fully covered with no co‑pays.
(b) Data Integration. Public health agencies receive de‑identified, aggregated Portal data for epidemiology consistent with HIPAA expansions.
(c) Chronic Disease Management. HHS shall publish standardized, value‑based care frameworks integrating telehealth and pharmacy networks.
(d) Emergency Preparedness. Maintain a surge fund equal to 2% of annual HTF revenues for federally declared emergencies.
(e) Community Health & Equity Fund (CHEF).

Purpose. Finance population health, equity, and SDOH initiatives that measurably reduce preventable morbidity and costs (e.g., screenings, community paramedicine, care coordination, language access, community health workers).
Funding Level (Within Existing Outlays). CHEF is funded within the HTF outlay cap (no increase in total outlays): 2% of HTF outlays in Plan Year 2; up to 3% in Plan Year 3; up to 4% in Plan Year 4 and thereafter, only if the HTF maintains the reserve threshold in Section 5(g)(3). If reserves fall below two months of outlays, CHEF automatically reverts to 2% until reserves recover. HHS shall publish quarterly reserve status reports and codify reserve‑trigger monitoring by rule.
Use of Funds. Competitive, time‑limited grants to public health agencies, Federally Qualified Health Centers (FQHCs), hospitals, and community‑based organizations tied to measurable outcome targets; renewal only upon performance.
Equity Reporting. All CHEF projects must report stratified outcomes and publish results on the NHP.
Administrative Cost. CHEF administration counts toward the 7% admin cap in Section 5(f).

SECTION 15. HEALTHCARE TECHNOLOGY AND INNOVATION

(a) Innovation Fund. Allocate 1% of HTF expenditures to R&D in AI‑assisted diagnostics, interoperability/cybersecurity, rural telemedicine, and digital/home‑based technologies.
(b) Partnerships. HHS may partner with universities and firms under public licensing.
(c) Intellectual Property. Technologies developed with HTF funds are publicly licensed on a non‑exclusive basis.

SECTION 16. STATE TRANSITION FRAMEWORK

(a) State Coordination. HHS shall establish regional offices to coordinate Medicaid and state program transitions into HTF.
(b) Waivers. Five‑year renewable waivers may pilot supplemental programs meeting or exceeding national standards.
(c) Funding Alignment. Federal Medicaid, ACA subsidies, and related flows are redirected to HTF for participating states to ensure fiscal neutrality.
(d) State Portals. States may integrate with the NHP under federal cybersecurity standards.

SECTION 17. FISCAL ACCOUNTABILITY AND ECONOMIC IMPACT

(a) Annual Economic Review. CBO and the JEC shall report annually on national health expenditures under this Act, macroeconomic effects, and comparisons to pre‑Act baselines, scheduled to precede any planned phase gate by at least 60 days.
(b) Efficiency Targets. If administration exceeds 7% of outlays or average reimbursement delays exceed 30 days, HHS must submit a corrective plan within 90 days.
(c) Price Transparency. Participating providers must publish machine‑readable HTF reimbursement rates; non‑compliance may incur penalties up to $100,000/day.
(d) Integration with Section 5. This Section consolidates financial reporting and transparency requirements and shall be read in pari materia with Section 5’s triggers, caps, and indexation to Core CPI.
(e) Phase Gate Adjustment. If the certifications in Section 7(a)(5) are not met, the relevant phase is delayed 12 months and HHS shall propose temporary adjustments under Section 5(g)(2) (≤0.5 percentage points to AMERICA Act payroll and/or Employer MOE) to achieve actuarial balance; Congress may disapprove by joint resolution.

SECTION 18. INTERNATIONAL HEALTHCARE COORDINATION

(a) Reciprocity Agreements. State and HHS shall negotiate reimbursement reciprocity for emergency and necessary care abroad.
(b) Medical Tourism Oversight. HHS shall monitor non‑resident utilization and ensure cost recovery.
(c) Global Data Standards. HHS shall collaborate internationally to align U.S. data standards with best practices.

SECTION 19. EVALUATION AND CONTINUOUS IMPROVEMENT

(a) Five‑Year Review. GAO shall conduct quinquennial reviews on coverage, efficiency, wait times, satisfaction, and financial stability, with recommendations to Congress and MAC.
(b) Public Feedback Loop. The NHP shall enable secure beneficiary feedback; HHS and MAC review semi‑annually.
(c) Adaptive Budgeting. Based on GAO findings, Congress may adjust contribution brackets, co‑pays, or reimbursement limits by joint resolution without reopening the entire Act.
(d) Patient & Caregiver Advisory Board (PCAB). Establish a national board of beneficiaries, caregivers, and disability/rural advocates; meet at least semi‑annually; HHS must respond in writing to recommendations within 90 days. Two PCAB members shall serve as non‑voting liaisons to the MAC under Section 6(e)(3).
(e) Regional Public Hearings. Hold at least one public hearing per region per year; publish transcripts and HHS responses on the NHP.

SECTION 20. LONG‑TERM SERVICES AND SUPPORTS (LTSS) — HCBS‑FIRST (CORE BENEFIT)

Scope. LTSS is an Essential Service with HCBS‑first delivery where clinically appropriate; institutional services are covered when HCBS cannot reasonably meet needs.
Eligibility. Functional eligibility shall be based on HHS standards assessing ADLs/IADLs and cognitive status; caregiver supports may be authorized.
Care Management. Person‑centered planning, caregiver training, respite, and care coordination are covered; choice of qualified providers is preserved.
Budget Guardrails. LTSS growth rates are subject to Core‑CPI updates with targeted adjustments for demographic shifts determined in the National Health Budget under Section 5(e).
Quality & Oversight. LTSS providers participate in QIP metrics tailored to functional outcomes, caregiver burden, and avoidable institutionalization.

SECTION 21. ERISA AND LABOR TRANSITION — CONFORMING AMENDMENTS

(a) ERISA Conforming.

No Duplicative Essential Benefits. Employee benefit plans governed by ERISA may not offer coverage duplicative of Essential Services; only supplemental benefits are permitted.
Sunset of ERISA Preemption for Essential Services. ERISA §514 preemption is inapplicable to Essential Services to the extent inconsistent with this Act.
Multiemployer Funds. May continue as supplemental benefit funds.

(b) Worker Transition & Reskilling Fund.

Purpose. Provide training, wage insurance (up to 70% wage replacement for 12 months, capped), relocation grants, and career services to workers displaced from health‑insurance administration and related sectors.
Administration & Funding. Administered by HHS/Labor; funded within HTF outlay caps up to 0.2% of HTF outlays, prioritized using evidence of displacement; coordinated with ADHC credits.
Reporting. Annual public report on enrollments, outcomes, and budget.

End of Bill.