A new fiscal architecture.

Americans have a complicated relationship with their own healthcare. Two-thirds (64%) now say ensuring coverage is the federal government’s job — but don’t agree on how. Almost all benefit from some form of public healthcare subsidy, whether they recognize it as one or not. Even the 60% of non-elderly Americans with employer-based coverage — what most people would call private insurance — exists partly because the government excludes it from taxable income. Add it up, and local, state, and federal tax dollars fund 47% of all U.S. health spending outright, with Medicare and Medicaid alone accounting for 39%.

As the portion of older adults climbs throughout the 21st century, Medicare spending will continue to grow. Nearly 79% of adults over 65 live with two or more chronic conditions. But aging is only half the math: Per-person healthcare costs are also rising faster than the economy is growing, and the Congressional Budget Office (CBO) attributes just over half of the coming decades’ growth in federal healthcare spending to that force alone.

Medicare’s trust fund depletes in 2033 –– earlier than expected, just as the population each program serves gets older and costlier to treat and the number of prime-age workers falls. There are inputs to consider: how the money is raised, and how it’s spent — and when it comes to healthcare, spending well should mean better outcomes, not just lower cost. This is the moment for wholesale change: a fiscal architecture rebuilt for the country we are becoming.

The agenda

Invest in what reduces cost: prevention and primary care coverage. Preventive care aligns outcomes and costs by stopping disease before it starts, or catching it during the early, treatable stages. The Supreme Court upheld no-cost preventive coverage for 150 million Americans in 2025, with one caveat: The ruling also makes the underlying coverage determinations more susceptible to change over time. That coverage needs to be actively maintained and expanded — made genuinely easy and appealing to use, not just technically available.

The deeper fix sits upstream of coverage itself: The U.S. spends only about 5 cents of every health care dollar on primary care, versus roughly three times that in other high-income countries — and that underinvestment is how routine, preventable conditions turn into late diagnoses and harder, more expensive treatment. By 2034, California will require health plans to spend a fixed minimum share of every healthcare dollar on primary care. The U.S. should follow suit and establish a national spending floor for primary and preventive care.

Build a public long-term care model. Roughly 70% of Americans over 65 will need long-term care of some kind during their lifetimes. And yet many Americans have no plan and no insurance for the long-term care most of them will eventually need. Washington State’s WA Cares Fund is the model to build on: Three years of payroll contributions without disruption, the first state in the country now paying long-term care benefits, and portability for Washingtonians who move. Seven more states — including California and New York — are already considering how to build their own versions.

Absent a federal mandate like Japan’s, we should encourage states to keep building the capped, early-stage benefit, and push for a federal program to cover catastrophic care. Catastrophic coverage only steps in once someone’s needs extend well beyond what any capped state benefit or private policy could reach. The WISH Act, a bill with both Democratic and Republican sponsorship, is a live, but stalled, opportunity.

Pay for care where it already works, and where it’s already happening: at home, often by family. Prior to the 20th century, most healthcare happened at home; hospitals were closer to poorhouses than places people went to get better. The shift to institutions followed advances in medical technology, professional training, and sanitary science — hospitals became worth going to. In the 21st century, reliable connectivity, heating, cooling, and running water mean many homes can now support real clinical care, not just recovery, and the evidence already shows it working: Telehealth increases preventative care adoption and hospital-at-home programs show lower emergency department use and lower in-hospital mortality than traditional inpatient care. With annual deaths projected to exceed annual births starting in 2030, it’s time to ask why most Americans say they want to die at home — but only about one-third do. The answer benefits everyone: more comfort for the individual, and real savings for the system. It’s time for the broader health ecosystem — patients, the profession, and institutions — to move toward what already works for both.

Family caregivers are already providing much of that at-home care, unpaid — 59 million of them provided labor worth an estimated $1 trillion in 2024, more than the country spent on Medicaid that year — a cost that appears in no budget, because it’s paid in foregone wages. The need is so obvious that solutions are coming from multiple directions: paid family leave covers eldercare in 14 states and D.C., caregiver tax credits enacted in eight states and federal coverage is pending in the bipartisan Credit for Caring Act, direct Medicaid payment to family caregivers are made in states like Indiana, Michigan, and California, and a bicameral bill to credit caregiving years toward Social Security benefits. The question isn’t whether to cover this labor, it’s which model will serve America best.

Face the elephant in the room: American healthcare needs a new fiscal architecture. Americans want coverage broad enough to invest in living well, not just living long. What’s missing is the political, social, and financial will to build it. This decade should be spent working toward consensus, not defeating the other party: aligning first on what to cover and what it costs, weighing opportunity cost against cost avoidance. CBO, Yale, and Urban Institute have each modeled the price tag for expanding care, and their estimates vary by trillions — proof we need more bipartisan work on the assumptions, not less. Only then does the harder question of funding follow: income tax, corporate tax, public funds — every lever should be on the table, spent on the presumption that health as a business must still answer to health as its purpose. With fewer workers supporting more retirees every year — payroll tax caps, retirement age, and immigration policy will need to be considered — the alternative is a country that keeps spending more and staying sicker: the highest price of all for growing old without a plan.