You wake up feeling wrong. Maybe it is pressure in your chest, a cough that has lasted three weeks, blood sugar running high, or a lump you cannot convince yourself is nothing.
You know the responsible thing to do is call the doctor, make the appointment, and find out what is wrong before a small problem becomes a large one. However, another question arrives first. How much will this cost me?
That question has become so ordinary that we barely notice how strange it is. We tell people to catch disease early, manage chronic conditions, get preventive screenings, fill prescriptions, and seek treatment before an emergency develops. Then we put a price tag between them and the care we tell them to get.
This is happening in a country that is not stingy about healthcare. The United States spent $5.3 trillion on healthcare in 2024. That is $15,474 per person and 18% of the entire economy.
We are having a healthcare debate because we spend an extraordinary amount and still have not answered one of the simplest questions a healthcare system can face: What should every person be able to count on when they get sick?
The answer does not require government to pay every medical bill, abolish private insurance, or pretend healthcare becomes free because taxpayers receive the invoice. There is another possibility. We could decide that beneath Medicare, Medicaid, employer insurance, private plans, deductibles, copayments, and networks, there should be a floor, a basic guarantee, a place below which we will not allow an American to fall simply because illness arrived before the money did.
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First, Define Basic
Before we can talk seriously about cost, we have to decide what we are promising. “Healthcare for all” can mean almost anything. A Basic Health Guarantee should mean something specific: the level of care necessary to keep ordinary medical problems from becoming preventable medical disasters.
For our purposes, that would include primary and preventive care, medically necessary basic diagnostics, essential medications, basic mental-health treatment, prenatal and maternity care, urgent care, emergency stabilization, and management of chronic conditions such as diabetes, high blood pressure, and asthma.
That is a substantial guarantee, but it is not an unlimited one. It does not have to promise every physician, procedure, drug, hospital, specialist, experimental treatment, or elective service without restriction or cost. Congress would have to establish where the guarantee ends and additional coverage begins.
The test should be understandable at the kitchen table. If you find a suspicious lump, you should be able to get it examined. If your blood pressure is dangerously high, you should be able to address it before it becomes a stroke. If diabetes can be managed through regular care, financial hardship should not be what turns it into kidney failure or an amputation.
Congress would still have to define what is covered, what is excluded, what cost-sharing is permitted, which medications qualify as essential, and how the package changes as medicine changes.
That is not a weakness. A guarantee without boundaries becomes an open-ended promise. Clear boundaries make it understandable, measurable, and accountable.
If we cannot tell Americans what the guarantee actually guarantees, we do not have a healthcare policy. We have a slogan.
A Floor Is Not a Ceiling
The Basic Health Guarantee does not require replacing the entire American healthcare system. The guarantee is the floor, and insurance remains available above it.
Private insurers could offer supplemental protection, broader networks, specialist coverage, additional drug benefits, dental and vision care, or services outside the guarantee. Employers could continue offering broader benefits.
Employment-based insurance remains the most common form of coverage, reaching 53.5% of the population for some or all of 2025. Average employer-sponsored family coverage cost $26,993 that year, with workers contributing $6,850 directly toward the premium.
A reform this large should not promise that existing coverage would remain unchanged. If government pays for services employer plans cover today, employers and insurers will respond. Some plans may become more supplemental.
Those changes must be measured because employer health insurance is part of worker compensation, but the governing principle is simple: your insurance can determine how much protection you have above the guarantee. It should not determine whether there is anything beneath you at all. Losing a job could still mean losing an employer plan. It should not mean losing basic care.
We Are Already Paying for Healthcare
Whenever someone proposes guaranteeing healthcare, the first question is usually how we will pay for it. That is a fair question, but it begins in the wrong place if it assumes Americans are not already paying enormous amounts.
In 2024, private health insurance spending reached about $1.645 trillion. Medicare accounted for about $1.118 trillion, Medicaid roughly $932 billion, and Americans paid another $557 billion directly out of pocket. We pay those dollars through taxes, premiums, employer contributions, deductibles, copayments, and medical bills.
The Congressional Budget Office (CBO) and the Joint Committee on Taxation project about $2.4 trillion in federal health-insurance subsidies and related tax preferences for 2026, including Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), employment-based tax preferences, marketplace subsidies, and smaller programs. That $2.4 trillion is not another pile of money to add to the $5.3 trillion. The figures measure different things and overlap, yet CBO estimates that 30 million people will still be uninsured in an average month in 2026.
That is the contradiction. The fiscal question is how much care is inside the guarantee we already purchase, how much existing spending can actually be redirected, and how much additional financing is necessary. Those are different numbers.
The Price Comes After the Design
Eventually, every healthcare proposal comes down to a number. How much would this cost?
The responsible answer is not $1 trillion, $1.5 trillion, or any other figure precise enough for a headline. Before we can price the guarantee, we have to build it. Cost depends on covered services, utilization, provider payment, patient contributions, medications, and interaction with existing coverage.
Expanding access would also cause some people who currently avoid care because of cost to use more of it. That is not an accidental side effect. It is partly the point. We cannot count expanded access as a benefit while pretending the additional treatment costs nothing.
Any eventual model should produce several scenarios—a restrained benefit, a middle option, and a broader version—showing total spending, realistic offsets, additional financing, and effects on households and employers. Americans do not experience healthcare spending as an economist’s category. They experience the premium, payroll deduction, deductible, prescription bill, copayment, and tax. Every one of those dollars belongs on the same ledger.
If taxes rise, say so. If premiums fall, include that. If employers save money, show where it goes. If households save money, show which households. If people use more healthcare because financial barriers have been removed, count that too. Only then should we put a price on the Basic Health Guarantee.
The Hard Questions Cannot Be Waved Away
None of this proves the Basic Health Guarantee would work. Good intentions do not create doctors, staff rural clinics, shorten appointment calendars, prevent fraud, or establish fair reimbursement rates.
Coverage and capacity are not the same thing. A guarantee written in Washington is not much of one if the nearest participating clinic is an hour away or the next appointment is six weeks from Thursday. Expanding access requires a provider strategy, especially in rural communities.
Reimbursement cannot be ignored. Pay too little, and providers may refuse to participate or struggle to remain viable. Pay too much, and a public guarantee can become another expensive way of pouring money into a sector that already consumes trillions.
“Essential medication” sounds simple until the only effective treatment costs thousands of dollars. A workable guarantee needs rules for lower-cost alternatives, medical necessity, exceptions, appeals, and high-cost drugs with no adequate substitute.
Then there are fraud, unnecessary treatment, administrative burden, and taxes.
If additional revenue is required after legitimate offsets are counted, Congress should say how much and who pays it. A $2,000 tax accompanied by a $4,000 reduction in premiums and deductibles produces one result. A $2,000 tax with no reduction in household healthcare spending produces another. Neither the word “tax” nor the word “free” tells us which happened.
Stewardship does not require perfect prediction. It requires government to expect consequences, measure them, publish the results, and change the law when reality proves an assumption wrong. A promise this large should have to survive the taxpayer, the doctor, the rural hospital, and the patient trying to make an appointment. It should have to survive contact with the real world.
Government Stewardship Means Showing the Work
A healthcare guarantee cannot depend on citizens simply trusting the people administering it. People should know what they are entitled to, what they may pay, how to appeal denials, how providers are reimbursed, and how the program is financed.
They should also be able to see whether it works. Are wait times rising? Are providers accepting new patients? Are rural communities gaining access? Are people receiving preventive care earlier? Are households spending less out of pocket?
If something is failing, publish it. If something is working, publish that too. Public money does not belong to the agency spending it or the president administering it. It belongs to the public.
The Square New Deal does not ask Americans to accept a larger government simply because the cause is worthy. It asks government to become more legible when it assumes greater responsibility.
Congress Writes the Guarantee
If the Basic Health Guarantee becomes a national obligation, the central decisions should not depend on whichever administration occupies the White House. Congress should write them.
Congress should define the benefit, eligibility, financing, broad reimbursement rules, cost-sharing, private-insurance interaction, transparency requirements, and agency boundaries. It must also ensure pricing is fair, not extractive. That means taking on big pharma and healthcare lobbyists and holding them accountable.
The executive branch would administer the program by processing payments, overseeing providers, collecting data, and updating technical standards. Medicine changes too quickly for Congress to legislate every drug and treatment protocol.
Some delegation is unavoidable, but there is a difference between giving an agency room to implement a rule and asking the agency to invent the rule. If the benefit expands, Congress should own that decision. If more revenue is required, Congress should vote for it. If part of the guarantee fails, the people’s branch should repair it.
Healthcare does not operate on four-year election cycles. A diabetic should not wonder whether basic treatment disappears after an inauguration. A rural clinic planning future staffing needs more certainty than a temporary executive policy.
The Basic Health Guarantee should belong to the law. Congress writes the rule. The executive executes it. The public gets to see both.
Healthcare Is Also Citizen Stewardship
A Basic Health Guarantee establishes a public obligation. It does not eliminate personal responsibility. The Square New Deal asks government, corporations, and citizens to do something.
Government should make basic care accessible. Healthcare businesses should operate under rules that recognize the enormous imbalance between a company selling medical care and a patient who needs it. Citizens should take reasonable responsibility for their own health when they can.
However, responsibility means little without the practical ability to exercise it. You cannot responsibly manage high blood pressure if you cannot afford the appointment where it is diagnosed. You cannot preach prevention while making preventive care one of the easiest expenses for a struggling family to postpone. You cannot prevent diabetes or obesity if healthy foods are unobtainable or financially out of reach.
The guarantee removes some of those barriers. The citizen’s responsibility does not disappear after the door opens.
Public financing also cannot become an excuse for government to supervise every private health decision. People make imperfect choices, and health depends on more than behavior. A government that begins deciding who lived responsibly enough to deserve basic treatment has crossed a dangerous line. The floor should remain the floor.
Doctors’ time is limited. Nurses’ time is limited. Hospital capacity is limited. Taxpayer money is limited. A guarantee creates a shared resource, not an infinite one.
Government sets a reasonable floor, and citizens use it responsibly. One makes responsibility possible. The other helps make the guarantee sustainable.
The Basic Health Guarantee
The simplest way to explain this proposal is that no American should be unable to see a doctor, receive preventive care, fill an essential prescription, or obtain medically necessary basic treatment because they cannot afford it. That is the Square New Deal Basic Health Guarantee.
It is not unlimited healthcare, government ownership of medicine, or the abolition of private insurance. It is a defined floor beneath the existing system. Above that floor, Americans can buy additional insurance, employers can offer broader benefits, and insurers can compete.
Underneath those choices is something that remains when employment changes, insurance disappears, or money becomes tight. That is the social contract being proposed, not equality of every medical benefit, hospital room, or insurance policy. It is a minimum level of security when health becomes uncertain.
We Already Made the Expensive Choice
A strange assumption is buried in American healthcare debates: that guaranteeing basic care would be the moment the country finally decided to spend serious money on healthcare. That moment happened a long time ago. America spent $5.3 trillion in 2024.
We have already made the expensive choice. We made it through taxes, Medicare, Medicaid, employer-sponsored insurance, private premiums, deductibles, copayments, prescription bills, and every medical bill that forces a family to decide which other expense can wait.
The unresolved question is what all that spending should guarantee. The Basic Health Guarantee does not answer by promising everything. It draws a line. Below that line, basic medical care should not disappear simply because a person cannot afford it. Above that line, there remains room for insurance, competition, individual choice, employer benefits, and personal responsibility.
Building that floor would be difficult and costly. Congress would face hard decisions about benefits, reimbursement, drugs, taxes, eligibility, capacity, and where basic care ends. That is why stewardship matters. Government should not promise what it cannot define, spend what it cannot account for, delegate fundamental decisions merely to avoid difficult votes, or ask citizens to trust a system whose results they cannot see.
Citizens have responsibilities too. A shared floor does not make medical resources unlimited or every personal decision someone else’s responsibility.
Stewardship asks more of everyone. Perhaps the question we began with needs to be turned around. Can America afford basic healthcare for everyone? After spending $5.3 trillion in a single year, that is no longer the most interesting question. The better question is how can a country spend $5.3 trillion on healthcare and still leave basic healthcare uncertain for anyone?
We already built the expensive system. Now we have to decide what the people paying for it can count on.
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Sources:
Centers for Medicare & Medicaid Services. NHE Fact Sheet. National Health Expenditure Data. Accessed September 30, 2026.
Congressional Budget Office. Federal Subsidies for Health Insurance, 2026 to 2036. July 23, 2026.
KFF. 2025 Employer Health Benefits Survey. October 22, 2025.
U.S. Census Bureau. Bunch, Lisa N., and Halelujha Ketema. Health Insurance Coverage in the United States: 2025. Current Population Reports, P60-291. September 15, 2026.
This sounds like a good starting point. Is there anyone in Congress who is ready to write, promote, file, and bring this up for a vote?
We spend $5.3 trillion a year on healthcare, and still too many of us ask "what will it cost?" before we ask "what is wrong?"
That is $15,474 for every person in America, yet 30 million of us will go without insurance in an average month this year.
We do not need free everything or the end of private insurance. We need a floor, a clear guarantee of basic care beneath the system we already pay for.
Read the full essay, then go to senate.gov and tell your senators that Congress should write this guarantee.
We are America, and no one among us should face a diagnosis afraid of the bill.