A long-form feasibility study examining how the United States could provide universal health insurance while retaining private healthcare delivery and regulated private insurance.
Could the United States establish universal health insurance while maintaining private healthcare delivery and regulated private insurance, and what would such a system require in financing, workforce capacity, provider payment, and implementation?
Last updated: September 22, 2026
The study separates published evidence from Leiflets calculations and policy assumptions. A model assumption is not presented as an official estimate, and an uncalibrated amount should not be read as a forecast.
This study examines whether the United States could establish universal health insurance without requiring the federal government to own hospitals, employ most physicians, or eliminate regulated private insurance.
The analysis starts from the existing U.S. healthcare system rather than assuming that the country could simply copy another nation's model. It examines current healthcare spending, existing public financing, employer-sponsored coverage, household costs, provider payment, prescription drugs, administrative spending, workforce capacity, wait times, long-term care and implementation risk.
The central policy scenario tested by Leiflets is a regulated universal-insurance system: everyone receives a core insurance entitlement, healthcare delivery remains predominantly private, regulated private plans may continue operating, and a public option guarantees coverage where private-plan competition is inadequate.
The study does not assume that universal coverage would be free or that all current healthcare spending could automatically be redirected into a new federal program. Instead, it tests how much financing would have to move from premiums and existing public programs into new contributions or federal revenue, while also examining whether the healthcare workforce could absorb increased demand.
These are provisional findings from the current evidence and model. They may change as the fiscal and distributional analysis is refined.
U.S. healthcare spending is already exceptionally large. The feasibility question is therefore not simply whether the country can devote trillions of dollars to healthcare; it already does. The harder questions concern how spending is collected, distributed, priced and controlled.
Replacing premiums and portions of existing public financing would require substantial employer, household and federal financing. Lower premiums or out-of-pocket spending for a household do not imply that the household bears no financing burden elsewhere.
International systems demonstrate multiple ways to achieve universal or near-universal coverage. The model studied here therefore allows regulated competing insurers and a public option rather than assuming that one federal insurer must process every claim.
Insurance coverage increases the ability to seek care, but insurance cannot by itself create physicians, nurses, mental health professionals, hospital capacity or appointment slots. Workforce expansion is therefore treated as a prerequisite rather than an afterthought.
Lower provider prices can reduce spending, but aggressive payment reductions can also affect capacity and provider participation. The model therefore tests regulated payment with rural, teaching, trauma, shortage and safety-net adjustments.
A credible final estimate would require distributional modeling, tax-base calibration and formal budget scoring beyond what this independent study can provide.
In this study, universal healthcare primarily means universal access to a core health-insurance entitlement. It does not necessarily mean that the government owns hospitals, employs physicians, prohibits private insurance or pays every healthcare bill directly.
This distinction matters because healthcare systems can separate the financing of care from the delivery of care. A government may establish universal insurance rules while hospitals and medical practices remain privately operated.
The study therefore distinguishes three concepts that are often treated as interchangeable in political debate:
Virtually everyone in the eligible population has access to a defined core insurance benefit.
One primary public payer performs most of the core insurance financing and payment functions.
Government owns or directly operates a substantial portion of the healthcare delivery system.
Evidence → calculation → assumption → uncertainty → finding. Published evidence and Leiflets assumptions are never treated as though they have the same evidentiary status.
Any universal-coverage proposal has to begin with what the United States already spends and how that spending is financed.
| Category | 2024 Spending | Share of NHE |
|---|---|---|
| National Health Expenditures | $5.3 trillion | 100% |
| Medicare | $1.118 trillion | 21% |
| Medicaid | $931.7 billion | 18% |
| Private health insurance | $1.645 trillion | 31% |
| Out-of-pocket spending | $556.6 billion | 11% |
| Hospital care | $1.635 trillion | 31% |
| Physician and clinical services | $1.110 trillion | 21% |
| Retail prescription drugs | $467.0 billion | 9% |
The national total includes spending that would not necessarily become part of the proposed core insurance benefit. It therefore cannot be compared directly with the model's $3.95 trillion planning target as though the difference represented automatic savings.
The United States may be able to establish universal core health insurance while retaining predominantly private healthcare delivery and regulated private insurance, but doing so would require substantial financing changes, provider-price regulation, administrative standardization, healthcare-workforce expansion and a multi-year implementation period.
This is the central scenario the Study will stress-test. It is a research construct, not a legislative recommendation.
Eligible residents would receive an automatic, portable federal entitlement to a defined core package of medical benefits.
Hospitals, physician practices, pharmacies and other healthcare providers could remain privately owned. Universal insurance would not require federal ownership of healthcare delivery.
Private and nonprofit plans could compete under national rules for benefits, risk adjustment, enrollment and consumer protection.
A public plan would compete with regulated plans and function as an insurer of last resort where adequate private-plan competition is unavailable.
Hospitals would transition toward population- and risk-adjusted global budgets rather than relying primarily on different prices negotiated with different insurers.
Physician payment would use a regulated fee structure with adjustments for specialty shortages, geography, rural access and other capacity needs.
Drug purchasing would combine negotiation, competition, evidence review and other pricing tools rather than assuming a single uniform discount.
Core services would use limited cost sharing with income-sensitive protections and an annual out-of-pocket ceiling.
Existing premiums would gradually be replaced by a combination of redirected public financing, employer health contributions, household contributions and additional federal revenue.
Long-term services and supports would not automatically be folded into the core medical-insurance benefit. Medicaid acute coverage and Medicaid LTSS would therefore require different transition paths.
Supplemental insurance could cover benefits outside the universal core package, subject to rules intended to preserve access to core services.
Workforce, rural capacity, behavioral health, residency training and administrative infrastructure would begin expanding before the system reaches universal enrollment.
The model changes how core healthcare is insured, financed and priced. It does not require the federal government to purchase hospitals or turn physicians into federal employees.
The financing model starts with a defined post-reform spending envelope rather than treating all current National Health Expenditures as the program budget.
| Component | Annual Amount | Evidence Classification | Status |
|---|---|---|---|
| Core universal medical-insurance target | $3.950 trillion | Leiflets model assumption | Central planning target |
| Existing public-financing bridge | $1.738 trillion | Leiflets calculation | Modeled proxy; not guaranteed transferable cash |
| Employer health contribution | $650 billion | Leiflets model assumption | Uncalibrated placeholder |
| Household health contribution | $300 billion | Leiflets model assumption | Uncalibrated placeholder |
| Remaining additional federal financing | $1.262 trillion | Leiflets calculation | Conditional on all preceding assumptions |
The $3.95 trillion planning target is intended to represent a post-reform spending envelope. If lower provider prices, administrative simplification or prescription-drug policies helped produce that target, those savings cannot also be subtracted again as independent financing sources.
The central financing result changes materially when the assumed employer or household contribution changes. The following table therefore presents a range rather than treating $1.262 trillion as an exact tax requirement.
| Scenario | Public-Financing Bridge | Employer Contribution | Household Contribution | Additional Federal Financing |
|---|---|---|---|---|
| Lower employer / lower household | $1.738T | $550B | $250B | $1.412T |
| Lower employer / central household | $1.738T | $550B | $300B | $1.362T |
| Lower employer / higher household | $1.738T | $550B | $350B | $1.312T |
| Central employer / lower household | $1.738T | $650B | $250B | $1.312T |
| Central case | $1.738T | $650B | $300B | $1.262T |
| Central employer / higher household | $1.738T | $650B | $350B | $1.212T |
| Higher employer / lower household | $1.738T | $750B | $250B | $1.212T |
| Higher employer / central household | $1.738T | $750B | $300B | $1.162T |
| Higher employer / higher household | $1.738T | $750B | $350B | $1.112T |
Replacing premiums does not eliminate the underlying cost of healthcare. It changes where and how that cost is collected.
The central model replaces much of the existing employer-premium system with a health contribution. The current $650 billion employer amount is a planning placeholder and has not yet been calibrated against payroll, firm size, industry or current employer health spending.
Many small employers do not currently offer health insurance. A flat employer contribution could therefore create a new direct expense for firms that do not currently pay premiums. The model anticipates graduated rates, exemptions or credits rather than assuming every employer can be treated identically.
Distributional analysis must compare the entire before-and-after household burden: premiums, employer compensation effects, deductibles, copayments, new contributions and taxes. Looking only at the new tax or only at the eliminated premium would give an incomplete result.
A progressive contribution schedule has been sketched for model testing, but the revenue estimate needs household microdata and formal behavioral modeling before it can be treated as a credible revenue score.
Coverage expansion is easier to finance if prices fall, but payment reductions that destabilize providers can undermine access.
The central model moves hospitals toward prospective annual budgets adjusted for population, service mix, quality and regional conditions instead of relying primarily on separate negotiated prices for every payer and service.
Physician payment would use regulated rates with adjustments for shortage specialties, geography and access needs. The model does not assume that every physician can simply be paid the current Medicare rate.
Hospitals that provide trauma, teaching, rural standby capacity or disproportionate safety-net services may require additional adjustments because simple volume-based payment does not capture the cost of maintaining those capabilities.
CMS has used and continues to test prospective hospital global budgets and multi-payer cost controls. That does not establish that a nationwide version would produce the same results, but it provides an existing U.S. policy and operational precedent.
International price comparisons show substantial differences, particularly for branded drugs, but those comparisons do not establish the exact price reduction achievable across the entire U.S. pharmaceutical market.
Policies that reduce expected pharmaceutical revenue can also affect research-and-development incentives. The final model therefore needs to evaluate both consumer savings and possible effects on future drug development.
Current Leiflets sensitivity range: roughly 2–3% in a conservative scenario, 5–7% in the central range and 10% or more only in a substantially more aggressive pricing scenario. These are model scenarios rather than forecasts.
Enrollment, claims, risk adjustment, fraud control, utilization management, quality measurement, appeals, customer service and plan administration would still exist. The relevant question is how much duplication and complexity could realistically be removed.
Reduced administrative spending may appear across insurers, employers, providers and government. It should not automatically be treated as cash available to finance the federal budget.
Coverage expansion can increase demand faster than healthcare supply can adjust. The model therefore treats workforce expansion as part of the financing and implementation problem.
| Workforce Measure | FTE / Positions | Classification |
|---|---|---|
| Projected U.S. physician shortage, 2038 | 141,160 | HRSA projection |
| Projected primary-care physician shortage, 2038 | 70,610 | HRSA projection |
| Projected registered-nurse shortage, 2038 | 108,960 | HRSA projection |
| Physicians added under Leiflets scenario | 35,000 | Leiflets model assumption |
| Registered nurses added | 100,000 | Leiflets model assumption |
| Nurse practitioners added | 30,000 | Leiflets model assumption |
| Physician assistants added | 20,000 | Leiflets model assumption |
| Mental-health counselors added | 80,000 | Leiflets model assumption |
| Medical assistants added | 75,000 | Leiflets model assumption |
| Community health workers added | 40,000 | Leiflets model assumption |
| Healthcare social workers added | 20,000 | Leiflets model assumption |
| Health-information and interoperability workers added | 20,000 | Leiflets model assumption |
| Total Leiflets ten-year workforce expansion | 420,000 | Leiflets model assumption |
Shortages are distributed unevenly across specialties and geography. Increasing the national number of clinicians does not guarantee additional primary-care, behavioral-health or rural capacity where shortages are most severe.
The proposed rollout starts residency expansion, nursing capacity, behavioral-health recruitment and underserved-area incentives before the full core entitlement takes effect.
Wait times are a capacity question, not simply a label attached to one financing system.
| System / Measure | Reported Result | Interpretation |
|---|---|---|
| Canada — hip replacement | 68% within 6 months | A substantial minority waited beyond the recommended benchmark. |
| Canada — knee replacement | 61% within 6 months | Wait-time performance remained below the pre-pandemic benchmark level. |
| Canada — cataract surgery | 69% within 112 days | Most patients received surgery within the benchmark, while a substantial minority did not. |
| Canada — radiation therapy | 94% within 28 days | Most patients received treatment within the benchmark. |
| Canada — hip-fracture repair | 83% within 48 hours | Most patients received treatment within the benchmark, while a meaningful minority did not. |
| United States — projected physician capacity | 141,160 FTE shortage by 2038 | The United States faces projected capacity constraints independently of whether universal coverage is adopted. |
Canadian priority-procedure data show meaningful delays for several elective procedures. A universal-coverage proposal should not dismiss that evidence.
International performance varies considerably. Coverage model, workforce capacity, provider payment, capital investment and demand management all influence access.
Existing and projected U.S. workforce shortages mean the counterfactual is not a system with unlimited immediate access. The relevant comparison is how access changes from the current U.S. baseline.
International systems provide evidence about possible institutional arrangements, but they are not plug-and-play estimates for the United States.
| Country | Coverage Model | Spending Per Capita (USD PPP) | Share of GDP | Doctors / 1,000 | Nurses / 1,000 | Core Coverage |
|---|---|---|---|---|---|---|
| United States | Mixed public/private multipayer | $14,885 | 17.2% | 2.7 | 12.4 | 93% |
| Germany | Statutory health insurance + private insurance | $9,365 | 12.3% | 4.7 | 12.2 | 100% |
| Netherlands | Mandatory regulated competing insurance | $8,436 | 10.0% | 3.9 | 11.1 | 100% |
| Australia | Universal public Medicare + private insurance | $7,469 | 10.3% | 4.2 | 13.0 | 100% |
| United Kingdom | Tax-funded National Health Service | $6,747 | 11.1% | 3.4 | 9.1 | 100% |
Germany, the Netherlands, Australia and the United Kingdom all provide universal core coverage through materially different combinations of public financing, regulated insurance and healthcare delivery.
Countries differ in prices, wages, demographics, benefit packages, workforce, long-term care, capital spending and accounting. International spending is therefore used as comparative evidence rather than a shortcut to a U.S. budget estimate.
The model does not assume that the current insurance system can be switched off and replaced nationwide on a single date.
| Period | Coverage | Financing | Capacity & Delivery | Institutional Transition |
|---|---|---|---|---|
| Year 1 | Build automatic-enrollment infrastructure and begin targeted coverage expansion for selected high-risk uninsured populations. | Existing coverage financing largely remains in place while replacement financing is developed. | Launch workforce, residency, community-health and rural-capacity investments. | Build eligibility, payment, risk-adjustment, cybersecurity and data infrastructure. |
| Year 2 | Continue early coverage expansion while testing enrollment and payment systems. | Begin federal transition funding while existing private and public coverage remains operational. | Expand training slots, primary care, behavioral-health capacity and underserved-area incentives. | Begin standardized administration, prior authorization and insurer-readiness testing. |
| Year 3 | Broader enrollment begins as administrative and regional capacity milestones are reached. | Introduce an initial employer contribution with small-business relief and transition provisions. | Deploy regional access monitoring and shortage interventions. | Begin hospital payment corridors and phased Medicaid acute-care integration. |
| Year 4 | Most eligible residents transition toward the universal core entitlement. | Employer financing ramps while household financing remains partially phased. | Additional physician, nursing and behavioral-health workforce enters service. | Public-option, risk-adjustment and national administrative standards operate at broader scale. |
| Year 5 | Universal core coverage entitlement becomes operational. | Employer and household financing move toward the mature structure. | Access standards and wait-time monitoring become systemwide requirements. | Medicaid acute coverage is substantially integrated while long-term services and supports remain a separate financing pillar. |
| Years 6–7 | Universal core entitlement remains in place while remaining transition gaps are addressed. | Mature recurring financing increasingly replaces temporary transition financing. | Continue targeted expansion in shortage specialties and geographic areas. | All-payer hospital budgets and regulated physician payment mature while workforce-transition assistance peaks. |
| Years 8–10 | Stable universal core entitlement. | Contribution rates, thresholds, reserves and spending growth are reviewed against observed fiscal performance. | Workforce and access targets are reassessed against actual utilization and regional demand. | Evaluate spending, outcomes, waits, provider stability, administrative performance and distributional effects. |
A household, employer or public program should not lose an existing coverage pathway until the replacement entitlement, enrollment record and provider-payment pathway have been verified. Coverage migration and financing migration therefore need to occur together.
Universal core entitlement is targeted around Year 5, while provider payment, workforce expansion, institutional integration and fiscal stabilization continue through approximately Year 10.
Enrollment systems, insurer transitions, provider payment, federal-state coordination, cybersecurity, workforce supply and cash-flow management create operational risks that a static budget estimate cannot capture.
Balancing the system in its first mature year is not enough. Healthcare spending and the revenue base can grow at different rates over time.
A system that begins in balance can develop a substantial financing gap if healthcare expenditures consistently grow faster than the revenue base. Cost growth therefore matters at least as much as the initial financing package.
The model would establish a long-run expenditure benchmark tied partly to economic and revenue growth, while permitting justified deviations for demographic change, emergencies, capacity expansion and high-value medical innovation.
The working model targets a reserve of approximately 2–4% of annual core expenditures. At a $3.95 trillion planning envelope, that corresponds to roughly $80–160 billion. The reserve would absorb temporary deviations rather than permanently financing structural deficits.
The model does not give an administrative board unilateral authority to impose federal taxes or revoke core coverage.
Long-term care is too large and structurally different from ordinary medical insurance to hide inside the core-benefit estimate.
The central model covers medical insurance rather than assuming that nursing-home care, long-duration home care and the full range of community-based support services can be added at no additional cost.
Medicaid currently finances substantial long-term services and supports in addition to acute medical care. Integrating Medicaid acute coverage into a universal medical entitlement therefore does not eliminate the need for a separate LTSS financing structure.
The working architecture therefore creates a separate American Long-Term Care Insurance pillar. Medicaid acute medical coverage could gradually migrate into the universal core entitlement while LTSS financing remains separately identifiable during the transition.
No national LTSS payroll contribution or other dedicated financing rate has been adopted in this Study. That component requires its own actuarial and distributional analysis.
Preventive and medically necessary dental and vision services could be incorporated into the universal benefit, but the $3.95 trillion planning target should not be assumed to finance an unlimited dental and vision entitlement without further costing.
The final package would need to define covered services, frequency limits, provider payment and patient cost sharing before dental and vision expenditures can be incorporated into the fiscal model.
Eligible residents would receive a core entitlement without depending on a particular employer.
Changing jobs, losing a job or moving between participating regions would not terminate the core insurance entitlement.
Where multiple plans operate, consumers could choose among regulated plans, with a public option available as a default or fallback.
Primary care and selected high-value services could carry little or no cost sharing, with income-sensitive protection for other services.
Core benefits, appeals, prior authorization and consumer protections would use more consistent national rules.
Private supplemental insurance could remain available for benefits outside the core package, subject to rules protecting access to core services.
The model does not require federal ownership of physician practices, hospitals or other ordinary healthcare delivery organizations.
Hospitals and clinicians would face less variation in prices across insurers, but the government and participating plans would have a larger role in determining payment methodology.
Standardized benefits, claims rules and prior authorization could reduce duplicated administrative work, while clinical documentation, fraud controls, quality measurement and appeals would remain.
A system that relies partly on lower prices cannot credibly promise that every provider would receive the same revenue as under current commercial insurance. Effects would vary by provider type and payment design.
A model cannot simultaneously claim large reductions in administrative labor costs and assume that no jobs or job functions change. Some positions could disappear, while others could move into new insurance, clinical-support or public administrative roles.
Attrition, retirements, vacancies, reassignment and retraining could absorb part of the transition. The gross ranges above should therefore not be interpreted as predictions of the unemployment effect.
A national entitlement, federal financing, insurance standards, employer rules and changes affecting existing federal programs would require congressional action rather than implementation through ordinary administrative authority alone.
States could retain implementation, regulatory and delivery responsibilities, particularly for provider oversight, long-term care and local capacity, while federal standards establish the national entitlement.
Many private-sector employer health plans are governed by ERISA, which also contains federal preemption rules affecting state regulation of covered employee benefit plans. Any federal transition involving employer-sponsored coverage would therefore need to specify how existing plans, employer contributions, collective bargaining arrangements and new federal requirements interact.
Major restructuring could generate legal challenges over federal authority, state responsibilities, payment rules and transition provisions. This Study does not assume that those disputes can be predicted or eliminated in advance.
Aggregate national affordability does not tell us whether a particular household, employer or industry would pay more or less.
That conclusion requires comparing current premiums, employer contributions, wages, deductibles and out-of-pocket spending with the proposed household contributions, employer contributions, taxes and remaining cost sharing for households across the income distribution.
A reform could reduce national healthcare expenditures while still increasing costs for some households, or increase national spending while improving financial protection for particular groups.
Employer health spending is part of employee compensation. Replacing premiums with employer contributions can therefore affect wages and compensation over time, not merely employer accounting.
A feasibility study should identify conditions under which its central scenario stops working.
Medical spending persistently grows faster than wages, GDP and the contribution base, producing a widening structural deficit.
Demand rises rapidly while physician, nursing, behavioral-health and facility capacity cannot adjust, increasing waits or reducing appointment availability.
Savings targets overwhelm the financial capacity of hospitals or practices, particularly rural, safety-net and shortage-area providers.
The system preserves too much of the existing price structure and fails to achieve the expenditure target.
Contributions impose disproportionate costs on smaller or lower-margin employers or create incentives to alter employment arrangements.
The contribution structure produces unexpected burdens across income groups or fails to raise the assumed revenue.
Eligibility, claims, payment or data systems are launched before they can reliably support nationwide enrollment and provider cash flow.
Future policymakers expand benefits or increase payment without corresponding financing, or repeatedly override mechanisms intended to control long-run spending.
Medicaid, LTSS, insurance regulation and provider oversight transitions produce gaps, duplication or incompatible rules.
Administrative, provider-price or drug savings prove smaller than assumed, increasing the financing requirement.
Coverage, insurance administration and healthcare delivery are separate design dimensions. International systems demonstrate multiple combinations of public financing, regulated insurance and private delivery.
The central fiscal question is therefore not simply whether the country can spend trillions of dollars on healthcare, but how existing and additional resources would be collected, redistributed and controlled.
Moving expenditures currently financed through premiums, employers and households into a universal framework changes the government's budget even if national healthcare expenditures do not increase by the same amount.
Provider-payment reductions can lower spending, but overly aggressive reductions can threaten capacity. Conversely, increasing coverage without expanding capacity can increase congestion and waits.
Workforce expansion, payment reform, enrollment infrastructure, insurer transition and federal-state coordination all require sequencing.
The Study can construct plausible aggregate financing scenarios, but determining who ultimately pays more or less requires household, employer and tax-base modeling that has not yet been completed.
The evidence reviewed so far does not identify a structural reason the United States could not operate a universal insurance system while retaining private healthcare delivery and regulated private insurance.
The model would, however, require substantial changes in financing, provider payment, prescription-drug purchasing, administration and healthcare capacity, together with a multi-year implementation period. Whether a particular legislative version would reduce total spending, improve household finances, increase federal deficits, change economic output or produce acceptable access depends on policy choices and behavioral responses that require additional distributional and formal budget analysis.
Existing healthcare spending provides a large resource base, but redirecting it requires taxes, contributions, payment changes or some combination of them.
Workforce supply, provider capacity and long-run healthcare cost growth can undermine a universal system even if enrollment and financing are successfully established.
The next stage is to determine whether a specific financing and benefit package can meet the model's goals without producing unacceptable distributional, fiscal or access consequences.
Published figures are drawn from the bibliography attached to the underlying research tables. Leiflets calculations, assumptions and uncalibrated model components are labeled separately throughout the Study.
Future revisions should update the fiscal model as newer CMS, CBO, JCT, HRSA, MACPAC, OECD and other authoritative data become available and should replace model placeholders when more rigorous calibration is completed.