Legislative summary
What Congress would vote on
HEALTH5 does not exist today. Creating it would take new federal law. This page sets out what that legislation would have to do, the choices left to lawmakers, and a responsible path to a vote.
The proposal in brief
HEALTH5 would establish a national minimum benefit covering medical, dental, vision, hearing and outpatient prescription drugs for qualified U.S. citizens, administered by competing private insurers under one national standard. It would remove insurer networks for covered care, pay providers through one standardized method, balance risk across insurers through a national pool, and finance coverage under a ceiling of $832 per person per month: $125 from the enrollee and $707 from employers, existing public programs and other authorized sources.
What the legislation would need to authorize
Each provision below is part of the HEALTH5 design. The right-hand column notes current federal law it would build on or change.
| Provision | What it would do | Current law it touches |
|---|---|---|
| National HEALTH5 benefit | Define a core benefit of medical, dental, vision, hearing and outpatient prescription drugs, offered as UHC-0 ($0 cost sharing) and UHC-5000 (cost sharing capped at $5,000 a year). | Federal minimum coverage standards for private insurance |
| Eligibility and enrollment | Cover qualified U.S. citizens, set buy-in rules for other eligible residents, and assign each enrollee to an insurer for five years, with defined exceptions. | Current enrollment and eligibility rules |
| No networks, standard payment | Let any participating licensed provider treat any member, set one geographically adjusted payment method, and prohibit balance billing for covered care. | Extends today’s surprise-billing protections (No Surprises Act) to all covered care |
| National risk pool | Authorize CMS to assign each enrollee a risk class from 1 to 10 and distribute members so insurers carry similar expected risk. | New statutory authority for CMS |
| Risk kept separate from price | Bar insurers from using allocation risk scores to raise an enrollee’s contribution. | Consistent with ACA rating rules that allow only age, tobacco, family size and geography (CMS) |
| At-fault conditions (optional) | If Congress chooses, allow a limited premium adjustment for conditions caused intentionally or negligently, with objective causation, appeals, independent review, a cap and expiration after 60 months. | Would require amending ACA rating rules (CMS) |
| Financing | Set the $125 enrollee contribution and the $707 balance; require employers with 20 or more employees to contribute; credit existing Medicare, Medicaid, ACA and employer dollars without double counting; allow deduction from retirement or benefit payments. | Employer health plans under ERISA (DOL) and existing program financing |
| Extended care | Cover up to 120 days a year of medically necessary skilled nursing, rehabilitation, home health and habilitation, separate from custodial long-term care. | Medicare and Medicaid post-acute benefits |
| Access standards | Set national appointment-wait standards with capacity investments: residencies, rural incentives, telehealth and advanced-practice clinicians. | |
| Program integrity | Prohibit billing arrangements designed to multiply billable events, with claims analytics, clinical review and appeal rights. | |
| Workforce Transition Corps | Fund a temporary corps that retrains affected administrative workers to build the new automation. | Can build on DOL apprenticeship programs (DOL) |
| Reserves and catastrophes | Require reserves and explicit catastrophe funding so pandemics and disasters don’t raise everyone’s contribution permanently. |
This is a policy summary, not bill text. Final legislative language, committee jurisdiction and interactions with existing law would be worked out with legislative counsel.
Decisions for Congress
The proposal leaves several choices to lawmakers:
- Should the $832 monthly ceiling be authorized as a pilot benchmark pending actuarial validation, or adopted only after full national modeling?
- How should the $707 balance be divided among employers, existing public programs, federal funding, state funding and other sources?
- Should UHC-0 and UHC-5000 both be offered nationally, or tested in selected markets first?
- What statutory authority is needed for national risk allocation, standardized reimbursement, balance-billing limits and five-year insurer assignments?
- Which access-to-care measures should trigger capacity investments when appointment waits exceed the standard?
- Should the at-fault condition category be included at all?
A responsible path to a vote
- Introduce the bill and request an independent cost estimate from the Congressional Budget Office and an analysis by CMS’s actuaries.
- Build the full actuarial and fiscal model, reconciling 2024 spending category by category (see the reconciliation tool).
- Hold public hearings in the committees with jurisdiction over health, tax and employer benefits.
- Vote, with the option of authorizing the $832 ceiling first as a pilot in selected markets.
- Phase it in, with access monitoring, the Workforce Transition Corps and published results at each stage.
Why vote for it
More coverage for a familiar price
Five benefits for about what employers and workers already pay for medical-only single coverage (KFF).
Less paperwork
CMS says standardized transactions let billing and payment be automated (CMS). HEALTH5 would standardize the whole claim path.
Private insurers stay
Insurers would compete on service and efficiency instead of risk selection, and keep selling supplemental coverage.
Workers aren’t left behind
A funded transition corps would retrain administrative staff instead of counting their jobs as instant savings.
The case for HEALTH5 rests on testing it honestly. The figures here are targets from the proposal, and the $832 ceiling is not yet actuarially validated. See what still has to be proven.
Sources for this page
- CMS, National Health Expenditure Fact Sheet (2024 data)Total 2024 spending of $5.3 trillion and $15,474 per person; hospital, physician and drug spending; Medicare, Medicaid and private insurance totals; sponsor shares.
- KFF, 2025 Employer Health Benefits SurveyAverage 2025 employer single premium of $9,325 a year, with workers paying $1,440 of it.
- CMS, Your rights and protections against surprise medical bills (No Surprises Act notice, PDF)Current federal surprise-billing protections, which HEALTH5 would extend to all covered care.
- CMS, Market Rating ReformsCurrent ACA rule: individual and small-group premiums may vary only by age, tobacco use, family size and geography.
- U.S. Department of Labor, Health Plans and Benefits (ERISA)ERISA sets protections and fiduciary standards for employer-sponsored health plans, which HEALTH5 legislation would need to address.
- U.S. Department of Labor, AI skills website and AI-focused Registered Apprenticeships (Apr. 29, 2026)Federal AI skill-building resources, including health care, and AI Registered Apprenticeship programs.
- CMS, About Administrative SimplificationCMS: standardized electronic transactions let the industry automate billing and payment, saving time and health care dollars.
Policy design details come from the UR2Big HEALTH5 Comprehensive Research and Policy Proposal (November 2026). See all sources.
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