Universal Coverage, State Competition

The Current Disaster

American healthcare is the worst of all worlds: the most expensive system on Earth that still leaves millions uninsured and millions more one illness away from bankruptcy.

We spend more per capita than any other nation. We don't get more for it. In many metrics — life expectancy, infant mortality, chronic disease management — we perform worse than countries that spend half as much.

The system is broken. Everyone knows it. No one fixes it.

Neither Extreme Works

The current debate is stuck between two bad options:

There's a third way — one that provides universal coverage while preserving competition and innovation.

The Autonomist Model: State-Based Pools

Remember how insurance used to work? Large groups pooled their risk. The healthy subsidized the sick. Everyone was covered because everyone was in the pool.

We propose bringing back pools — at the state level.

Why State Pools Work

1. Large pools spread risk. A pool of millions spreads risk efficiently. The healthy subsidize the sick — that's what insurance is supposed to do. No one is uninsurable because everyone is in.
2. Competition happens at the right level. Instead of competing to avoid sick customers, insurers compete to win state contracts. The incentive shifts from "deny claims" to "deliver value." States can switch providers if performance is poor.
3. States become laboratories. 50 states means 50 experiments. Some will try different approaches. Best practices will emerge. States can learn from each other. This is federalism working as intended.
4. Negotiating power is massive. A state pool negotiating on behalf of millions has real leverage with hospitals, drug companies, and providers. No more $500 aspirin. Prices come down when buyers have power.
5. Administration simplifies. One insurer per state means one set of forms, one set of rules, one system to navigate. The administrative bloat that consumes 30% of current spending shrinks dramatically.
6. Employers are freed. Businesses no longer need to provide health insurance. They can focus on their actual business. Workers are no longer trapped in jobs for the insurance. Entrepreneurship becomes less risky.
7. Portability is automatic. Move to a new state? You're in that state's pool. No COBRA. No coverage gaps. No paperwork. Just continuous coverage.

What About Choice?

A common objection: "I want to choose my own insurance!"

Do you, though? Most people hate dealing with health insurance. They want to choose their doctor, not their insurance company.

Under this model:

• You choose your doctor. The pool contracts with providers, but you pick which ones you see.
• You can buy supplemental coverage. Want more than the standard package? A private market for supplemental insurance can exist.
• You can pay out of pocket. Want a service not covered? Pay for it yourself. Autonomy preserved.
• States can offer options. Some states might offer tiered plans — bronze, silver, gold — with different cost-sharing levels.

The goal is universal coverage, not universal sameness.

How It's Funded

This is where the Digital Dollar closed loop changes everything.

Currently, healthcare is funded through a byzantine mix:

• Employer premiums (hidden in lower wages)
• Employee premiums (deducted from paychecks)
• Medicare taxes (payroll deduction)
• Medicaid (state and federal taxes)
• Out-of-pocket costs (deductibles, copays)
• VA funding (federal budget)

All of this gets replaced by one thing: a portion of the D$ transaction fee.

The amount dedicated to healthcare is visible and debatable. If we want more coverage, the dial goes up slightly. If we want less, it goes down. The debate is honest.

The Transition

We can't flip a switch overnight. The transition requires:

Phase 1: Build the Pools (Years 1-3)

• States establish pool structures
• Standard benefits package defined (with state flexibility)
• Bidding process created for insurers
• IT infrastructure built for enrollment and claims

Phase 2: Transition Enrollment (Years 3-5)

• Medicaid enrollees move to state pools
• Uninsured automatically enrolled
• Employer plans begin transitioning
• Medicare remains for current seniors (grandfathered)

Phase 3: Full Operation (Years 5-10)

• All non-Medicare residents in state pools
• Employer-sponsored insurance phased out
• Private supplemental market matures
• System optimization based on experience

Long Term: Medicare Integration

• New seniors enter state pools instead of Medicare
• Medicare phases out over decades as current beneficiaries age
• Eventually: one system for all, birth to death

What This Isn't

• Not single-payer. There's no single national insurer. Each state has its own pool, its own contract, its own approach. Competition and federalism preserved.
• Not government-run healthcare. The government doesn't employ the doctors or run the hospitals. Private providers compete for patients. The state just organizes the insurance pool.
• Not socialized medicine. You're not assigned a doctor. You choose your providers. You can pay for additional services. The market still functions.
• Not the status quo. Universal coverage. No more medical bankruptcy. No more job lock. No more uninsured.

The Autonomist Healthcare Principles

1. Everyone is covered. No one falls through the cracks. No one is uninsurable. Healthcare is a baseline, not a privilege.
2. No one is bankrupted by illness. Catastrophic costs are absorbed by the pool. Getting sick doesn't mean losing everything.
3. Prices are transparent. You know what things cost before you receive them. No surprise bills. No hidden charges.
4. You choose your providers. The insurance is assigned; the doctors aren't. You pick who treats you.
5. Competition improves quality. Insurers compete for state contracts. Providers compete for patients. Innovation continues.
6. States experiment and learn. Federalism means 50 approaches. Best practices emerge. One size doesn't fit all.
7. Funding is honest. Healthcare costs are visible in the D$ rate. The debate is real. No hidden taxes.
8. Employers are freed. Health insurance is not their job. They can focus on business. Workers can focus on work.