Proposal № 004 of 250 · Released July 4, 2026
CitizenCare
Single-payer health coverage for every American citizen, from birth, for life — and honest, mandatory private coverage for guests.
The problem
America spends more on health care than any nation in history — roughly 17 percent of GDP, more than $13,000 per person per year — and gets mid-table outcomes, medical bankruptcies, and 25 million uninsured for the money. The waste is not mysterious: a thicket of billing intermediaries whose administrative costs run several times Medicare's, and a system where losing your job means losing your doctor.
And there is a quieter cost. Citizenship in America currently entitles you to a passport and jury duty. If membership in the nation carries no protection you can feel in your body, we should not act surprised that membership feels thin.
The proposal
CitizenCare: every American citizen is enrolled at birth — the same registry that opens your Dividend share under № 001 — in comprehensive, single-payer coverage. No premiums, no networks, no eligibility paperwork, ever. The citizen's card is the insurance card.
Non-citizens are covered honestly rather than accidentally: every sojourner (№ 003), student, and visitor must carry qualifying private coverage, priced into their visa. Guests are cared for — no one bleeds out at an American curb — but through paid coverage, not emergency-room cost-shifting.
This is the covenant made concrete, and it is a pair with the border: a nation generous enough to insure every member can be unapologetic about knowing who its members are. Protection is unconditional for citizens. It is provided-and-paid-for for guests. That is not a contradiction; it is the yin and yang of a functioning family.
How it would work
- Financing swap, not new spending: employer premiums and employee premiums — money families already pay, about $25,000 a year for the average employer family plan — convert to a payroll contribution that is smaller for the great majority of households. Existing Medicare, Medicaid, and CHIP spending folds in.
- Glide path by cohort: everyone under 18 and over 55 enrolls in year one; the ring closes over eight years. Insurers exit gradually; the million-plus Americans who work in billing get first claim on the system's new administrative and care-navigation jobs.
- Innovation preserved: NIH — the actual engine of American biomedical discovery — is expanded, and drug pricing uses international reference bands with a guaranteed-margin floor so the pipeline keeps its economics.
The numbers
Estimates of federalizing health spending run in the tens of trillions over a decade — the Mercatus Center's widely cited figure was $32.6 trillion — and honesty requires saying that word out loud. But the same studies show national health spending roughly flat or falling, because the federal line item replaces premiums families already pay. The question is not whether Americans spend the money — they demonstrably do — but whether they keep routing 15 to 30 cents of each dollar through paperwork that Medicare does for about 2.
The honest objections
"Wait times." Rationing exists in every system; ours rations by price and paperwork instead of queues, which is why Americans skip prescriptions at the highest rate in the rich world. The transition plan front-loads capacity: residency slots, nurse licensure compacts, rural clinics — bottlenecks are a construction problem, not a law of nature.
"It's socialism." It's Medicare, extended to your children. Medicare has been running for sixty years and is the most beloved institution in American life after the military. The reddest state in the union (Alaska) cashes a socialized dividend check every October; the country will survive a citizen's insurance card.
"You're creating second-class care for guests." Guests carry real coverage as a visa condition — many will hold better plans than today's uninsured citizens. What ends is the pretense: care billed to no one, priced into everyone.
"The disruption." Half of Americans already move through public coverage (Medicare, Medicaid, VA, CHIP). The cohort glide path means no one's coverage changes overnight — and no one under 18 ever again asks what a deductible is.