Universal Health Security

Premiums rise every year. Deductibles continue to grow. Small businesses struggle to provide coverage. Millions of Americans remain tied to jobs they would otherwise leave because they fear losing their health insurance. Currently, Americans pay for healthcare through insurance premiums, deductibles, co-pays, co-insurance, and taxes. The current system is expensive, fragmented, and unfair. Every American should have access to affordable basic and catastrophic healthcare coverage. No American should go bankrupt because they get cancer, suffer a serious accident, develop a chronic illness, or experience a medical emergency.

The current debate usually presents Americans with only two choices: keep the existing system despite rising costs and growing complexity, or adopt a national all-inclusive Medicare for All system administered entirely by the federal government. Neither choice is viable nor honest with voters. The Medicare for All Act currently in Congress has real support — more than 100 House Democrats have signed on — but it has no Republican support and no path to a majority. I believe there is room for a more practical conversation.

I support either of two approaches that can achieve universal healthcare coverage while reducing waste and administrative costs. Both include reasonable cost-sharing, because that is what makes reform durable and able to earn votes from both parties.

Option One: State-Based Health Insurance

Under this approach, the federal government would collect health insurance funding — the equivalent of what Americans currently pay into employer-sponsored premiums and ACA marketplace premiums — and distribute it to the states, combined with existing federal Medicare and Medicaid funding.

Each state would expand its existing Medicaid program into a public healthcare system covering all residents — not a new bureaucracy built from scratch, but a scaled-up version of infrastructure that already works — with states free to design systems that reflect the priorities of their citizens while meeting national standards for coverage and catastrophic protection.

Virginia is especially well-positioned for this path. We already made the hard choice to expand Medicaid in 2019, and today the program Cardinal Care covers more than 2 million Virginians through a functioning network of managed care providers. We are not starting from scratch. We already know how to run a large public health program well, and we could scale it quickly and efficiently.

Under this model:

• Some states may choose lower taxes and higher deductibles.
• Some states may choose higher taxes and broader, low-cost-sharing coverage.
• Some states may choose multiple plan options.
• Americans can still purchase private insurance to cover gaps.
• States can levy additional taxes to ease cost-sharing burdens on their residents.

This approach respects federalism and lets states function as laboratories of democracy, while still guaranteeing every American coverage.

Option Two: National Health Insurance

Under this approach, the federal government would expand and modernize Medicare into a national health insurance system covering all Americans, with Medicaid incorporated into Medicare.

• Coverage rules would be standardized nationwide.
• Administrative costs would be reduced through a single national claims and reimbursement structure.
• Every American would receive the same baseline coverage regardless of where they live.
• Americans can still purchase private insurance to cover gaps.

This approach maximizes simplicity, portability, and administrative efficiency.

One Important Caveat

For those that are skeptical of “government run healthcare,” to make it clear, neither solution is “government run healthcare” like the U.K. — the insurance is provided by the government, but the care is delivered through the private sector. This distinction is important, as those that are free market purists are generally right that the private sector is usually better for providing goods and services, but this is only when trade is a positive-sum game. Insurance is a zero-sum game.

Which Option Do I Prefer?

I am open to either approach. My priority is not whether insurance coverage is administered primarily from Richmond or Washington. My priority is whether Americans receive affordable healthcare coverage and whether the system delivers better outcomes at lower cost. If Congress can build a broad coalition around a state-based model, I will support it. If Congress can build a broad coalition around a national model, I will support it. I am more interested in solving the problem than winning an ideological argument.