How it would work
The law would set one national standard for who is covered, what is covered and how providers are paid. Private insurers would still run it, and compete to run it well.
No networks
Under HEALTH5 there would be no insurer-specific provider networks for covered care. Any participating licensed provider could treat any member. Providers would accept the HEALTH5 rate as payment in full, and balance billing would be prohibited.
That would remove a whole category of work and conflict: network contracting, network directories, network eligibility checks, out-of-network bills, network exceptions and disputes about network status. CMS already recognizes that standardized transactions let billing and payment be automated (CMS, Administrative Simplification), and it is pushing payers toward standard APIs for prior authorization (CMS-0057-F final rule).
One transparent way to pay providers
Networks are one of the tools insurers use to negotiate prices today, so HEALTH5 would have to replace them with a clear national payment method. “PPO rate” isn’t enough, because PPO rates vary by insurer, provider and region. CMS would test:
- Regional commercial benchmarks
- A percentage of Medicare rates (Medicare spent $1.118 trillion in 2024, CMS)
- Blended commercial and Medicare schedules
- Adjustments for geography and specialty
- Special protection for rural and critical-access providers
The goal: pay high enough to keep providers participating, while removing unnecessary price variation and paperwork.
A balanced risk pool
Today insurers can profit by attracting healthy members and avoiding sick ones. HEALTH5 would end that. CMS would give each accepted applicant a risk class from 1 to 10 based on factors such as age, diagnoses, prescriptions and use of care, then spread members so every participating insurer got about the same expected risk.
Your risk score wouldn’t set your price. The risk score would be used to balance insurers, not to charge patients. Someone with an expensive condition they did nothing to cause may get a high score for allocation and still pay the standard contribution.
Conditions caused by the insured
The proposal includes a separate category for conditions an insured person caused intentionally or through negligence. This would need its own carefully drafted federal legislation, with strict safeguards:
- Objective medical evidence of cause, and defined negligence standards
- Written findings, appeal rights and independent medical review
- A maximum allowed premium adjustment
- Automatic expiration after 60 months
The overwhelming majority of illnesses and injuries would stay no-fault.
Paying for care, not for paperwork
A standard payment system should stop billing arrangements whose main purpose is to create extra billable events. That includes unnecessary duplicate transportation, services split up to bill more, duplicate testing, avoidable facility charges, and moving services between related companies to bill again.
Necessary care is reimbursed. Artificially multiplying billable events is not.
Medically necessary transportation and legitimate outsourcing would stay fully covered. Claims analytics and AI-assisted fraud detection would flag unusual patterns, while clinical review and appeal rights stayed in place.
Shorter waits
Coverage alone doesn’t create doctors, nurses, dentists, hospital beds or rural clinics. HEALTH5 would set national access-to-care standards and track the number of days to an appointment for each major type of service.
More capacity
Residency expansion, rural incentives and qualified advanced-practice clinicians.
Better reach
Telehealth and interstate practice where authorized.
Faster handoffs
Electronic referrals and rewards for providers who open more appointments.
Private insurers would stay in
HEALTH5 would not abolish private insurance. Insurers would compete to administer the standard benefit, and win on:
- Service and customer satisfaction
- Administrative efficiency and technology
- Care coordination
- Fraud control and cost management
They would also keep selling products beyond the core benefit, from supplemental indemnity and long-term care to enhanced dental and life insurance with living benefits.
Sources for this page
- CMS, About Administrative SimplificationCMS: standardized electronic transactions let the industry automate billing and payment, saving time and health care dollars.
- CMS, Interoperability and Prior Authorization Final Rule (CMS-0057-F)CMS's move toward APIs and standardized data exchange to automate prior authorization between payers and providers.
- 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.
Policy design details come from the UR2Big HEALTH5 Comprehensive Research and Policy Proposal (November 2026). See all sources.
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