The reforms we feature run along a continuum from less to more comprehensive in their coverage and impact on government costs. They range from a set of incremental improvements to the ACA to a single-payer plan similar to some “Medicare for All” proposals. For a brief summary of our methods, see “How We Conducted This Study” below. For those seeking additional background on our methods as well as additional findings and discussion, see the full version of this report here.

The first six reform packages build on one another; the last two are alternative approaches to a single-payer health system.

Reforms that build on the ACA:

1. ACA Enhanced I: Improves the ACA’s current premium and cost-sharing subsidies and adds a reinsurance program for the individual market to protect insurers against very high claims.

2. ACA Enhanced II: In addition to the above reforms, this package includes restoration of the ACA’s individual mandate penalty and reversal of the Trump administration’s expansion of short-term, limited-duration plans.

3. ACA Enhanced III: This package builds on Reform 2 by closing the Medicaid eligibility gap for adults with very low incomes in states that have not expanded their Medicaid program. It also introduces a limited autoenrollment mechanism for most people receiving benefits from the Temporary Assistance for Needy Families (TANF) or Supplemental Nutrition Assistance Program (SNAP) programs.

4. ACA Enhanced IV: Adds to the reforms in #3 a public plan option and/or a capping of the provider payment rates in private nongroup insurance plans.

5. Universal Coverage I: The first reform plan to achieve universal coverage, this builds on #4 by enabling workers to opt for subsidized nongroup coverage instead of their employer’s insurance plan and introducing a mechanism through which all legal U.S. residents are deemed insured. This reform features a public option in the nongroup market.

6. Universal Coverage II: Adds to #5 by boosting premium and cost-sharing subsidies further.

Single-payer plans:

7. Single Payer “Lite”: A single-payer plan that covers all people legally residing in the U.S. and includes all the ACA’s “essential health benefits.”1 There is cost-sharing for individuals pegged to income (consistent with those in reforms 1–5) but no premiums. There is no private insurance option.

8. Single Payer Enhanced: This plan covers all U.S. residents, including undocumented immigrants, and features a broader set of benefits than Single Payer “Lite,” including adult dental, vision, and hearing care as a well as a home- and community-based long-term services and supports benefit. In addition, there are no cost-sharing requirements. There is no private insurance option.

Highlights in Brief

Each reform option improves the affordability of health insurance considerably through lower premiums and cost-sharing and broader public program eligibility. Reductions in consumer costs are greatest in the single-payer plans. But as affordability increases, the taxes necessary to finance the reforms would increase as well.

Reaching true universal coverage requires either an autoenrollment mechanism for those not voluntarily enrolling in insurance or a single-payer system that enrolls the entire population in a single plan.

Employer coverage falls as the generosity of assistance in the individual market increases. The single-payer options eliminate employer coverage (and other private insurance) altogether.

In general, federal spending increases as subsidized coverage becomes more generous and more people enroll. However, the individual mandate, reinsurance, and cost-containment strategies like the introduction of a public plan option, can also lower the federal funds necessary to finance reform.

If the employer insurance system remains largely intact, universal or near-universal coverage can be achieved with reasonably moderate increases in federal spending.

Under our Single Payer “Lite” reform (#7), total national spending on health care falls relative to current law. But under the more expansive Single Payer Enhanced reform (#8), national health spending increases, because the costs of additional coverage, greater benefits (more services and no household cost-sharing), and coverage of 11 million undocumented immigrants exceed the savings from lower provider payment rates and administrative costs.

The Reforms: Projected Impacts

Below we present our estimated changes in health insurance coverage, federal government spending, and total national health spending (combined costs to employers, households, government, and uncompensated care delivered by health care providers) under each reform option, compared to current law. In addition, we show the increase in federal revenues needed to finance each reform after netting out any additional income tax revenues that result from reductions in employer-based insurance and corresponding wage increases.2 For ease of comparison, all estimates are based on reforms as if they are fully phased in and in equilibrium in 2020 — meaning that the number of providers has grown to meet the new demand for services and that households and employers have completely adjusted their coverage decisions in response to policy changes.

The components of all of the reforms simulated are summarized in the table below. In addition, descriptions accompany the analytic findings for each reform package.