Last Updated: July 28, 2026
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The American Health Security Act

Constitutional Authority: Article I, Section 8 (Taxing and Spending Clause — federal health insurance program structured as a public option in the mold of Medicare and Medicaid, both upheld for half a century; the ACA’s individual mandate and Medicaid expansion specifically upheld in NFIB v. Sebelius (2012) as exercises of the Taxing and Spending powers); Article I, Section 8 (Commerce Clause — federal regulation of the interstate health insurance market, longstanding); Medicare Modernization Act of 2003 and Inflation Reduction Act of 2022 (the existing statutory framework for Medicare drug price negotiation, now extended to the public option); Affordable Care Act of 2010 (the framework for subsidies and marketplace operations extended by this Act). The public option is structurally simpler than the ACA private-insurance regulations and rests on more settled constitutional ground — Medicare has been the constitutional model for public health insurance since 1965. Prescription drug price negotiation: settled authority since the IRA, now expanded. Hospital price regulation: well-precedented under existing Medicare prospective payment system; expansion to non-Medicare markets relies on Commerce Clause authority similar to the existing Hospital Price Transparency Rule (CMS, 2021).

Rationale: The United States spends nearly twice as much per capita on healthcare as any other developed country and gets worse outcomes by virtually every measure — lower life expectancy, higher infant mortality, higher maternal mortality, more medical bankruptcies, more uninsured. This is not because Americans are sicker or American medicine is worse. It is because the system is structurally designed to extract maximum financial return from each medical encounter, rather than to deliver health. Insurance companies profit from denying care. Hospital systems profit from monopoly pricing in consolidated regional markets. Pharmacy Benefit Managers profit from opaque rebate structures. Drug companies profit from patent thickets that prevent competition. The result is a system that is one of the largest line items in the federal budget, one of the largest line items in every household budget, and one of the leading sources of personal bankruptcy — while still leaving 30 million Americans uninsured and tens of millions more underinsured. The public option does not abolish private insurance — it gives every American the choice of a public alternative that competes on cost and coverage. Direct drug price negotiation does what every other developed country already does. Hospital price transparency and regulation address the consolidation that has made hospital pricing opaque and exploitative. This is not “Left vs. Right.” It is “Working vs. Broken.” Healthcare is the foundation beneath the rest of American life — and right now it is broken in ways that no other developed democracy tolerates.

Public Health Insurance Option: Design Parameters

The public health insurance option is the centerpiece of healthcare reform, providing a government-administered plan that competes with private insurance while offering comprehensive coverage at lower cost. This section outlines key design decisions and implementation considerations.

Core Design Principles:

Access and Eligibility:

Relationship to Existing Coverage:

Benefits Package Design:

Benefit Scope (Two Options):

Option A: Medicare-Equivalent (“Medicare for More”)

Option B: Comprehensive (“Platinum Plus”)

Recommended: Start with Option A (Medicare-equivalent) to minimize costs and facilitate CBO scoring, with Option B offered as premium tier or phase in dental/vision/hearing over Years 2-3.

Cost-Sharing Structure:

Provider Network and Payment Rates:

Network Strategy (Three Options):

Option A: Medicare Provider Network

Option B: Open Network (All Licensed Providers)

Option C: Negotiated Network (Hybrid)

Recommended: Start with Option A (Medicare network) for administrative simplicity, with Option C as fallback if provider participation insufficient.

Provider Payment Rates:

Balance Billing Prohibition:

Premium Structure and Affordability:

Income-Based Premium Sliding Scale:

Income Level (% of FPL) Monthly Premium (Individual) Annual Premium (Family of 4) % of Income
<138% FPL $0 $0 0%
138-200% FPL $50 $200 2-3%
200-300% FPL $150 $500 4-5%
300-400% FPL $250 $850 6-7%
400-500% FPL $350 $1,200 8%
>500% FPL $450 $1,600 8-10%

Comparison to Private Insurance:

Subsidy Mechanism:

Administration and Operations:

Administering Agency:

Enrollment and Customer Service:

Claims Processing:

Technology Infrastructure:

Fraud Prevention:

Enrollment Projections and Market Impact:

Conservative Enrollment Estimates:

Optimistic Enrollment Estimates:

Market Competition Effects:

Transition from Medicaid:

Cost Analysis and Financing:

Annual Cost Projections:

Enrollment: 15 million (Year 1, Conservative)

Enrollment: 25 million (Year 3, Moderate)

Enrollment: 40 million (Year 5, Conservative Steady-State)

Offset by System-Wide Savings:

Net Impact:

Implementation Timeline:

Days 1-60 (Design Phase):

Days 61-120 (Draft Legislation):

Days 121-180 (Refinement and CBO Scoring):

Months 6-12 (Legislative Process):

Year 2 (Buildout Phase):

Year 3 (Launch):

Years 4-5 (Optimization):

Political Strategy and Stakeholder Management:

Coalition Building:

Opposition and Counterarguments:

Private insurance industry: “Government takeover, kills private insurance”

Providers: “Medicare rates too low, threatens access”

Fiscal conservatives: “Unaffordable, adds to deficit”

Constitutional challenges: Unlikely (ACA upheld, government insurance programs well-established)

Communication Strategy:

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This page is part of Project 2029: A Mandate for Economic and Political Justice