A fiscally balanced, hybrid single‑payer that guarantees essential care for everyone, reins in prices, and preserves choice.
What AMERICA Act Does
- Universal coverage for essential services (modeled on Medicare benefits) for all citizens and lawful residents; non‑residents billed at cost + admin.
- Hybrid model: keep supplemental private insurance and HSAs for non‑essential services and amenities.
- Free choice of providers: no networks, no prior auth for essentials; telemedicine covered at parity (80% of in‑person reimbursement).
How It’s Paid For (Four Pillars)
- AMERICA Act Payroll — employer doubled share (≈12.67% effective) + employee 5%–9.5% band (floor at 105% FPL; cap 9.5%).
- Medicare Realignment — HI payroll + Parts B/D general revenues redirected to the HTF.
- Medicaid MOE — federal & state maintenance‑of‑effort dollars into the HTF.
- Employer MOE — replaces premiums: ≥7.5% of payroll or prior‑year health spend (inflation‑adjusted).
Indexation: Payment updates, caps, and automatic triggers are tied to Core CPI (not CPI‑M).
Progressive Co‑Pays (OOP cap = 5% of AGI)
- Low‑income: $0 for essentials except modest ER/ambulance/hospital/day and $10 Rx;
- Middle: PC $20, Specialist $50, Rx $20, Labs $10, ER $100;
- High / Very‑High: 2× / 3× middle co‑pays;
- Annual OOP capped at 5% of AGI (auto‑refunded above cap).
Cost Controls (Built‑In)
- All‑payer global hospital budgets with growth cap Core CPI + 0.5pp.
- Site‑neutral payments; facility‑fee limits for outpatient, imaging, labs, telehealth.
- HTF‑wide drug negotiation (class‑based, cost‑plus, international reference pricing).
- Admin cap ≤7%; AI‑assisted anti‑fraud with human oversight.
2026 Fiscal Snapshot (billions)
| Amount | |
|---|---|
| HTF Outlays (Year 1 reformed) | $5,389 |
| Total Inflows (MOE at 5%, Year 2 rate) | $5,451 |
| Operating Balance | +$62 |
| HI Trust Fund opening reserves (§7(f)) | +~$225 |
| Total Year 1 HTF Reserves | ~$287 |
Funding mix (2026, billions): AMERICA Act payroll $2,617, Medicare HI payroll $413, Employer MOE $665 (5% rate — phases to $998 by Year 4), Medicare B/D $750, Medicaid MOE $950, Co‑pays $55.
See the funding waterfall: 
Year 1 is lean by design. Outlays of $5,389B reflect partial savings realization; Employer MOE at 5% ($665B) rather than the full 7.5% ($998B). This matches how every major federal health program launched — Medicare (1966) and Part D (2006) both started lean and grew into financial strength within 2–3 years. The HI Trust Fund transfer provides the opening buffer.
Multi‑Year Path (phased cost‑control caps)
- Outlay growth: Core CPI+2.5pp (Years 1–2) stepping to Core CPI+0.5pp (Year 11+ long-run target) — consistent with France, Taiwan, and Canadian provincial precedent.
- Employer MOE: 5.0% → 6.25% → 7.5% (Years 2–4), fully phased by Year 4.
- Annual surpluses grow from +$62B (Year 1) to +$886B (Year 10). 10-year cumulative HTF surplus: ~$5.1T.
- 2026–2033 projection:
Transition (Years 1–5)
- Year 1: Stand up HTF & Portal; publish site‑neutral schedule; pilot hospital budgets.
- Year 2: Consolidate Medicare (HI + Parts B/D) into HTF; begin national global budgets; Employer MOE at 5%.
- Years 3–4: Raise Employer MOE to 7.5%; complete Medicaid MOE; phase in mental health & vision parity.
- Years 2–5: Phase out private insurance for essentials; preserve supplemental markets.
Links
- Full updated bill (Markdown): AMERICA Act Bill Text
- Back‑of‑the‑envelope appendix + waterfall: Financial Model - Back of Envelope
- Microsim + re‑modeled financials: Simulation and Reformed Model Financials