This proposal is offered to the American people through the High Country Advocate. We encourage all candidates, elected officials, policy organizations, and citizens to respond. Congress returns in January. Premiums double without action. Primary elections begin in March. You have 120 days. Explain why this won’t work, or explain why you oppose something that would save American families thousands of dollars annually. The American people are watching, and they vote in 90 days.
What Just Happened
On December 11, 2025, the Senate voted on competing healthcare bills. Both failed 51-48. Enhanced Affordable Care Act subsidies expire December 31. Without congressional action, premiums double for 22 million Americans starting January 1, 2026. Neither party offered a real solution—Democrats proposed extending a failing system for three years, Republicans offered health savings accounts that can’t pay premiums.
Congress leaves town next week for holiday recess. They return in January facing voters who just saw their healthcare costs double. Primary elections begin in March. The political calendar is closing.
The Immediate Solution
Congress should pass a 120-day extension of ACA enhanced subsidies through April 30, 2026. This prevents the January 1 premium spike while providing time to implement a real solution. During those 120 days, Congress passes and implements the Real Care Act. RCA becomes fully operational before primary season, giving every American access to affordable catastrophic coverage and forcing both parties to defend their positions to voters.
The choice is clear: extend a failing system permanently, or use 120 days to fix the underlying problem.
The Problem
Americans pay twice what other developed countries pay for healthcare with worse outcomes. The Affordable Care Act didn’t fix this—it subsidized high prices while forcing healthy people to overpay for coverage they don’t need. The December 11 Senate votes proved neither party will solve this crisis because both answer to insurance companies and hospital systems spending $700 million annually on lobbying.
This proposal solves the problem both parties claim to care about while threatening the industries that fund their campaigns. That’s why it won’t pass—not because it wouldn’t work, but because it works too well.
The Real Care Act (RCA)
Core Principle
Americans need protection from medical bankruptcy, not comprehensive insurance for routine care they can pay themselves. The Real Care Act provides catastrophic coverage through voluntary Medicare buy-in at cost, eliminates the insurance company middleman, and creates real price transparency so people can shop for healthcare like any other service.
Coverage Structure
Individual Catastrophic Coverage
- Premium: $100/month ($1,200/year)
- You pay first $10,000 out-of-pocket
- Government covers everything above $10,000 at 100%
- Annual out-of-pocket maximum: $10,000
- Total annual exposure: $11,200 maximum
Family Catastrophic Coverage
- Two adults: $200/month ($2,400/year)
- Children under 18: $40/month each
- Adult children (ages 26-30): $75/month each
- Family pays first $20,000 out-of-pocket (shared among all members)
- Government covers everything above $20,000 at 100%
- All family members count toward single shared maximum
Example – Family of 6 (2 adults, 4 children):
- Monthly premium: $360 ($200 adults + $160 children)
- Annual premium: $4,320
- Family out-of-pocket maximum: $20,000
- Maximum annual exposure: $24,320 total
What’s Covered Above the Threshold
Once you reach out-of-pocket maximum ($10,000 individual, $20,000 family):
- Hospitalizations
- Emergency care
- Surgery
- Cancer treatment
- Chronic disease management
- Prescriptions
- Mental health treatment
- Rehabilitation
- All medically necessary care
No lifetime limits. No annual limits. No coverage denials.
What You Pay Cash For (Below Threshold)
- Annual checkups
- Urgent care visits
- Prescriptions for minor illnesses
- Routine lab work
- Minor procedures
Required price transparency means you can shop. Doctor visits cost $100-150. Basic lab work costs $50-100. You pay what you would have paid under ACA deductibles anyway, but without $7,200-10,800 in premiums.
Enrollment
Year-round enrollment:
- Sign up anytime at Medicare.gov
- Coverage starts first day of following month
- No enrollment windows
- No qualifying life events required
- Switch plans with 30-day notice
Who can enroll:
- Anyone under 65 not covered by Medicaid
- Works alongside employer coverage (can opt out and buy RCA instead)
- Private catastrophic insurance still available for those who want it
Price Transparency Requirements
Before any non-emergency treatment, providers must:
- Provide binding written price quote
- Include all costs (facility, physician, anesthesia, labs)
- Quote valid for 90 days
- Criminal penalties for billing beyond quoted price
- No surprise billing under any circumstances
Safe harbor provision:
- Any patient can pay Medicare rates for any service
- Providers cannot sue for difference between their charge and Medicare rate
- Eliminates price discrimination against uninsured/cash-paying patients
Medicare Drug Price Negotiation
- Extend current Medicare drug negotiation to all drugs
- Reference pricing to average of Canada, UK, Germany, France, Japan
- Veterans Affairs already does this successfully
- Applies to catastrophic coverage and cash purchases
Comparison to Current ACA
Family of 6 (2 adults ages 35-45, 4 children under 18)
Current ACA – Family making $80,000:
- Annual premium with subsidies: $7,200
- Family deductible: $14,000
- Out-of-pocket maximum: $18,200
- Maximum annual exposure: $25,400
Current ACA – Family making $120,000:
- Annual premium with subsidies: $10,800
- Family deductible: $14,000
- Out-of-pocket maximum: $18,200
- Maximum annual exposure: $29,000
Real Care Act – Any income:
- Annual premium: $4,320
- Family out-of-pocket maximum: $20,000
- Maximum annual exposure: $24,320
Annual savings:
- $80,000 income family: $1,080-4,080
- $120,000 income family: $4,680
Young Adult Age 26
Current ACA:
- Individual premium: $300-400/month ($3,600-4,800/year)
- Deductible: $7,500
- Out-of-pocket maximum: $9,450
- Maximum annual exposure: $13,050-14,250
Real Care Act:
- Individual premium: $100/month ($1,200/year)
- Out-of-pocket maximum: $10,000
- Maximum annual exposure: $11,200
Annual savings: $1,850-3,050
Alternative – Stay on parents’ policy:
- Parents add adult child: $75/month ($900/year)
- Share family out-of-pocket maximum
- Coverage until age 30
Part-Time Worker Making $24,000
Current ACA:
- Monthly premium: $400
- Monthly subsidy: $250
- Net monthly cost: $150 ($1,800/year)
- Deductible: $7,500
- Maximum exposure before insurance pays: $9,300
Real Care Act:
- Monthly premium: $100 ($1,200/year)
- Out-of-pocket maximum: $10,000
- Maximum annual exposure: $11,200
- Saves $600 in premiums
- $1,900 difference in exposure, but saved premium can fund HSA
Why Critics Will Attack This
Attack: “High deductibles hurt poor people”
Reality:
- Current ACA family out-of-pocket max: $18,200 plus $7,200-10,800 premiums = $25,400-29,000 total
- RCA: $24,320 total including premiums—lower total exposure
- Working poor (above Medicaid, below comfortable) hurt most by ACA premiums they can’t afford
- Family making $60,000 pays $7,200 ACA premiums—that’s 12% of income
- Same family pays $4,320 under RCA—saves $2,880 for rent, food, childcare
- Current ACA forces working poor to skip coverage entirely; RCA makes it affordable
Attack: “Preventive care won’t be used without free coverage”
Reality:
- Annual checkup costs $150 cash under price transparency
- Current ACA: Pay $7,200-10,800 premiums for “free” $150 checkup
- RCA: Pay $4,320 premiums + $150 cash = $4,470 total—saves $2,730-6,330
- People skip care NOW because they can’t afford premiums, not because checkups aren’t free
- Uninsured rate increased after ACA because premiums became unaffordable
Attack: “Medicare will go bankrupt”
Reality:
- This is PAID catastrophic coverage at actuarial cost, not free Medicare
- Medicare overhead runs 2% vs. private insurance 20%
- Adding healthy catastrophic-only buyers improves Medicare finances—they pay premiums, rarely use
- Current Medicare problem is unlimited coverage for elderly; this is limited (only above $10,000-20,000 out-of-pocket)
- CBO would score as revenue-positive for Medicare
Attack: “Insurance death spiral—healthy people leave comprehensive pool”
Reality:
- Already happening—ACA premiums doubled since 2021 because healthy people left
- Current system forces healthy people to overpay; RCA lets them buy appropriate coverage
- Young healthy people going uninsured now would ENTER system at $100/month
- Medicare catastrophic pool is national—much larger than state exchanges, spreads risk better
- Private comprehensive insurance still available; this creates competition, not elimination
Attack: “This is socialism/government takeover”
Reality:
- This is voluntary buy-in at cost, not mandatory government coverage
- Private insurance still exists for comprehensive coverage
- Current ACA forces people to buy insurance—that’s more government control
- Medicare already exists for 65+ million seniors—this extends what government workers already have
- If Medicare is socialism, current Medicare and federal employee coverage are already socialist
- Republicans who make this argument get Medicare at 65—why is it good for them but not 35-year-olds?
Attack: “Hospitals can’t survive on Medicare rates”
Reality:
- Hospitals accept Medicare rates for 65+ million seniors right now
- If unsustainable, hospitals would refuse Medicare patients—they don’t
- Hospital consolidation created monopolies charging 3-4× Medicare rates to private insurance
- Cleveland Clinic, Mayo, Johns Hopkins accept Medicare rates and remain profitable
- Rural hospitals closing NOW under current system because people can’t afford coverage, don’t pay bills
- Better to receive Medicare rates than be stiffed by uninsured patients
Attack: “Young people won’t sign up”
Reality:
- Won’t sign up at $300-400/month—correct
- Will sign up at $100/month—less than cell phone bill
- One ER visit costs $15,000-50,000—bankruptcy risk is real
- Parents will add 26-year-olds for $75/month
- Can enroll anytime, not just during enrollment window
- 2025 data shows millions of young people bought ACA coverage when subsidies made it affordable
Attack: “This eliminates insurance industry jobs”
Reality:
- Insurance companies can still sell comprehensive coverage
- Administrative jobs processing claim denials aren’t socially valuable
- Healthcare should serve patients, not protect insurance company profits
- Those workers can process Medicare catastrophic claims instead
- Buggy whip manufacturers employed people too—progress eliminates inefficient industries
Attack: “People will abuse the system”
Reality:
- $10,000-20,000 out-of-pocket before government pays—massive skin in the game
- More than current ACA deductibles of $1,400-3,000
- Catastrophic events (cancer, major surgery) aren’t discretionary—can’t abuse them
- Routine care paid cash with price transparency creates price sensitivity
- Medicare already has fraud detection
The Political Reality
Why This Won’t Pass
It threatens the wrong industries:
- Insurance companies lose captive market of healthy people forced to overpay
- Hospital systems lose monopoly pricing power through price transparency and Medicare rates
- Pharmaceutical companies lose monopoly pricing through Medicare negotiation
- These three industries spend $700 million annually lobbying Congress
Campaign contributions matter more than solving problems:
- Democrats take money from healthcare industry, oppose high deductibles despite lower total costs
- Republicans take money from insurance companies, oppose Medicare expansion despite voluntary buy-in
- Both parties keep healthcare crisis alive to fundraise on it
What Each Party Claims vs. What RCA Delivers
Democrats claim to want: ✓ Medicare expansion—RCA provides it ✓ End medical bankruptcy—RCA ends it through $10,000-20,000 caps ✓ Affordable coverage for working families—RCA cuts premiums 40-60% ✓ Reduced out-of-pocket costs—RCA provides lower total exposure
Republicans claim to want: ✓ Personal responsibility—RCA requires $10,000-20,000 out-of-pocket before government coverage ✓ Free market competition—RCA mandates price transparency and year-round shopping ✓ Voluntary, not mandatory—RCA eliminates individual mandate ✓ Reduced government spending—RCA costs less than current ACA subsidies
Both parties get what they claim to want. Neither will pass it.
The Political Calculation
Why Democrats should support this:
- Young progressives drowning in premiums will mobilize for $100/month catastrophic coverage
- Working-class voters who left Democrats partly over healthcare costs get $2,880-6,330 annual savings
- “We expanded Medicare to all ages and cut premiums in half” wins 2026 midterms
- Bernie Sanders and Elizabeth Warren both support Medicare expansion—this is it
Why Republicans should support this:
- Young Trump voters struggling with gig economy get affordable coverage
- Families save $4,000-6,000 annually—money in pockets, not insurance companies
- “We eliminated the individual mandate and gave Americans freedom to choose” message
- Beats Democrats at their own game on healthcare
Why neither will: Campaign contributions from healthcare industry exceed electoral benefits of solving the crisis.
Cost Analysis
Government Cost
Current ACA subsidies: $50-60 billion annually
RCA catastrophic coverage cost:
- Catastrophic-only coverage requires minimal government expenditure
- Participants pay premiums covering expected costs up to out-of-pocket max
- Government covers only expenses above $10,000 individual/$20,000 family
- Most enrollees never reach threshold in any given year
- Major catastrophic events (cancer, major accidents) already covered by current safety net programs
- Medicare administrative overhead 2% vs. private insurance 20%—efficiency savings
- Estimated cost: $40-45 billion annually—$10-15 billion less than current ACA subsidies
Revenue offsets:
- Medicare drug price negotiation saves $15-20 billion annually (CBO estimate)
- Reduced emergency room uncompensated care (currently $50+ billion annually)
- Reduced Medicaid emergency coverage for underinsured
- Net government cost potentially neutral or positive
Economic Impact
Annual savings to Americans:
- 22 million ACA enrollees: average $2,000-4,000 per household = $44-88 billion
- 25-30 million currently uninsured: protection from medical bankruptcy
- Small businesses: no longer must provide expensive employer coverage
- Total economic benefit to households: $50-100 billion annually
Administrative efficiency:
- Current system: insurance company takes 20% for overhead and profit on $4 trillion healthcare spending = $800 billion
- Medicare overhead: 2%
- Potential savings from eliminating insurance middleman: $720 billion annually in system
Implementation Timeline
Emergency 120-Day Implementation (January-April 2026)
Week 1-2 (Early January):
- Congress passes 120-day ACA subsidy extension through April 30
- Congress passes Real Care Act authorizing legislation
- President signs both bills
Week 3-6 (Late January-Early February):
- HHS issues catastrophic coverage regulations
- CMS modifies Medicare eligibility to include under-65 catastrophic buy-in
- Price transparency requirements take effect immediately
- Provider safe harbor provisions activated
Week 7-10 (Mid-February-Early March):
- Medicare.gov enrollment portal opens for catastrophic coverage
- Provider networks expanded
- Medicare rate schedules published for all services
- Claims processing systems operational
Week 11-16 (March-April):
- Public enrollment campaign launches
- Year-round enrollment begins
- First catastrophic coverage effective dates (March 1)
- ACA enhanced subsidies phase out April 30
- Full transition complete by May 1
Timeline ensures: RCA fully operational before primary elections begin in March-April 2026. Every candidate faces voters who have access to $100/month catastrophic coverage alternative.
Standard Implementation (If Congress Acts Later)
Month 1-3: Regulatory Framework
- HHS issues catastrophic coverage regulations
- CMS expands Medicare eligibility criteria
- Price transparency enforcement mechanisms established
- Provider safe harbor provisions implemented
Month 4-6: System Development
- Medicare.gov enrollment portal modified for under-65 enrollment
- Provider network agreements expanded
- Claims processing systems updated
- Fraud detection protocols adapted
Month 7-9: Provider Preparation
- Hospitals and physicians receive price transparency training
- Medicare rate schedules published for all services
- Safe harbor provisions activated
- Billing system updates completed
Month 10-12: Public Enrollment Launch
- Open enrollment for catastrophic coverage begins
- Year-round enrollment continues indefinitely
- ACA enhanced subsidies phase out as enrollees transition
- Private insurance competition continues alongside
Call to the American People
Neither party will pass the Real Care Act because it solves the healthcare crisis instead of enriching the industries funding their campaigns. But the December 31 deadline creates leverage. Congress must act before premiums double January 1.
The immediate demand:
Pass a 120-day extension of ACA enhanced subsidies through April 30, 2026, paired with Real Care Act implementation. This prevents January premium spikes while fixing the underlying problem. Congress returns in January. Primary elections begin in March. They have 120 days to deliver a real solution before voters decide who deserves their jobs.
The question for your representatives:
Do you oppose the Real Care Act because it’s bad policy, or because your donors oppose it? Explain to families paying $7,200-10,800 in annual premiums why they should keep subsidizing insurance company profits instead of saving $2,880-6,330 annually. Explain to 22-year-olds working two part-time jobs why $300-400 monthly premiums they can’t afford are better than $100 catastrophic coverage. Explain to parents of 26-year-olds why they can’t add adult children to family coverage for $75/month.
For candidates in 2026:
Healthcare will be on the ballot. Premiums doubled in January because Congress failed to act. Americans know the current system doesn’t work. They’re waiting for someone to offer a real solution. The Real Care Act is on the table. Where do you stand?
The challenge to both parties:
You failed on December 11. You have one more chance before premiums double January 1. Pass a 120-day ACA extension and implement the Real Care Act. You’ll return from holiday recess facing voters whose premiums just doubled, or voters who have access to $100/month catastrophic coverage. Primary challenges begin in March. You have 120 days to prove you care more about solving problems than protecting donors.
The Real Care Act gives Democrats their Medicare expansion and Republicans their free-market competition. The 120-day transition prevents January premium spikes while implementing a real solution. If you oppose this, explain why to voters—with specifics, showing your math—before they vote in primaries starting March 2026.
The Real Care Act solves the problem. The 120-day window makes it possible. The question is whether you have the courage to act, or whether you’d rather face voters in March who just watched their premiums double because you protected insurance company profits.
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