This Act may be cited as the "Secure Affordable Federal Essential Care Act" or the

"SAFECARE Act".

Sec. 1. Short title.

Sec. 2. Table of contents.

Sec. 3. Congressional findings and purpose.

Sec. 4. Definitions.

TITLE I. ESTABLISHMENT OF THE SAFECARE PLAN.

Sec. 101. Establishment.

Sec. 102. Administration.

Sec. 103. Universal entitlement.

Sec. 104. Essential health services.

Sec. 105. Limitation on duplicative private coverage.

TITLE II. FINANCING AND THE SAFECARE TRUST FUND.

Sec. 201. SAFECARE Trust Fund.

Sec. 202. Employer health contribution.

Sec. 203. Individual health contribution and reconciliation.

Sec. 204. Point of service cost sharing, prohibition on deductibles, and annual caps.

Sec. 205. Replacement of Medicare Hospital Insurance payroll taxes and coordination with

existing Federal health revenues.

Sec. 206. Trust Fund reserve stabilization and automatic rate adjustments.

Sec. 207. General fund reliance reduction and dedicated funding convergence.

TITLE III. ELIGIBILITY, ENROLLMENT, AND CONTINUITY.

Sec. 301. Eligible individuals.

Sec. 302. Automatic enrollment.

Sec. 303. Identification and records.

Sec. 303A. Data systems readiness, incremental deployment, and certification.

Sec. 304. Continuity of coverage.

TITLE IV. PROVIDER PARTICIPATION, PAYMENT, AND PRESCRIPTION DRUG.

PRICING

Sec. 401. Participation agreements.

Sec. 402. Payment methodologies and rate setting.

Sec. 403. Unified billing and prohibition of surprise billing.

Sec. 404. Reduction of administrative burden.

Sec. 405. National formulary negotiation and most-favored-nation prescription drug pricing.

TITLE V. HEALTH WORKFORCE AND EDUCATION REFORM.

Sec. 501. Tuition caps for health professions programs.

Sec. 501A. Health Professions Education Support Payments.

Sec. 502. Grant and service scholarship programs.

Sec. 503. Workforce Relief Loan Forgiveness Program.

Sec. 504. Priority service areas and specialties.

TITLE VI. NON MEMBER CARE AND SAFETY NET.

Sec. 601. Safety Net Care Fund.

Sec. 602. Emergency, maternity, contagious disease, and limited public health primary care

services for non members.

Sec. 603. SAFECARE Bridge option.

Sec. 604. Essential Infrastructure Capital Grants.

(e) Regional Capacity Review. Prior to awarding a Strategic Innovation Grant exceeding 10,000,000 dollars, the Secretary shall certify that the investment addresses a documented gap in regional clinical capacity and does not create duplicative supply of services already adequately available in the service area.

TITLE VII. MEDICAL DEBT REDEMPTION.

Sec. 701. Medical Debt Redemption Facility.

Sec. 702. Acquisition and cancellation of medical debt.

Sec. 703. Consumer protections.

TITLE VIII. FRAUD, WASTE, AND ABUSE CONTROLS.

Sec. 801. National Health Claims Data Platform.

Sec. 802. Real time fraud detection and pre payment review.

Sec. 803. Federal felony penalties for systemic fraud.

Sec. 804. Performance, value, and integrity monitoring using advanced analytics and AI.

TITLE IX. MEDICAL LIABILITY AND MALPRACTICE REFORM.

Sec. 901. Purpose and scope.

Sec. 901A. National Clinical Standards Board.

Sec. 902. Safe harbor for adherence to national clinical standards.

Sec. 903. Limitation on noneconomic damages.

Sec. 904. Health courts and specialized panels.

Sec. 905. Malpractice insurance rate review.

Sec. 906. Reporting and patient safety integration.

Sec. 907. Preservation of State procedures.

TITLE X. TRANSITION AND INTEGRATION OF EXISTING PROGRAMS.

Sec. 1001. Integration of Medicare, Medicaid, CHIP, and ACA subsidies.

Sec. 1002. Veterans health care.

Sec. 1002A. Indian Health Service.

Sec. 1003. Federal employee and other Federal health programs.

Sec. 1004. Private coverage transition rules.

Sec. 1005. Phased implementation schedule.

Sec. 1006. State administrative coordination payments.

TITLE XI. GENERAL PROVISIONS.

Sec. 1101. Regulations.

Sec. 1102. Severability.

Sec. 1103. Effective dates.

Sec. 1104. Amendment to Internal Revenue Code for data sharing.

(a) Findings. Congress finds the following.

(1) In 2024, United States health care spending was approximately 5.3 trillion dollars. This was

about 15,474 dollars per person and 18.0 percent of gross domestic product. (Centers for

Medicare and Medicaid Services)

(2) Federal subsidies and spending for major health programs and health insurance, including

Medicare, Medicaid, the Children's Health Insurance Program, and marketplace subsidies, are

projected to total about 25 trillion dollars over the 2024 to 2033 period. (Congressional Budget

Office)

(3) The Congressional Budget Office and related analyses project that spending on Social

Security and major health care programs will grow from about 10.7 percent of gross domestic

product in 2024 to about 14.1 percent by 2054 if current law continues.

(4) Despite high spending, health outcomes in the United States often lag behind other high

income countries. Comparative analyses attribute a large portion of the difference to higher

prices, administrative costs, and fragmented financing rather than to higher use of services.

(5) Recent estimates suggest that total waste in the health care system, including administrative

complexity, pricing failures, overtreatment, and fraud, amounts to between 760 billion and 935

billion dollars per year.

(6) Administrative complexity alone accounts for hundreds of billions of dollars in annual

spending, including roughly 200 billion dollars a year on financial transaction related

administration and at least half a trillion dollars in broader administrative waste and overhead

that does not improve health outcomes.

(7) Medical debt is widespread. A 2022 KFF survey found that about 41 percent of adults had

debt due to medical or dental bills. More recent work estimates that 11 to 18 percent of adults

currently carry medical debt and that the total burden is on the order of 200 to 220 billion dollars.

(8) Analyses of credit records and survey data show that medical debt is a major contributor to

housing instability, delayed care, and financial distress, including among insured households.

(9) Nearly one third of national health expenditures are for hospital care alone, which totaled

about 1.5 trillion dollars in 2023. Rising hospital prices and complex cost shifting add to

household and employer burdens.

(10) Per capita health care expenditures are projected to grow from about 16,570 dollars in 2024

to approximately 24,200 dollars by 2033 if current trends continue. This implies an average

annual per capita growth rate of about 4.6 percent, which outpaces wage growth for many

workers and threatens fiscal stability.

(11) Medical education debt is a significant barrier to balanced workforce supply. Recent data

show that typical medical school graduates carry debts around 200,000 dollars or more, which

pushes them toward higher paying specialties and away from primary care and underserved

areas.

(12) Persons who are physically present in the United States, regardless of status, can spread

contagious disease if they do not receive basic emergency and public health services. Failure to

provide such care endangers citizens and lawful residents and increases long term costs.

(13) Current systems for detecting and punishing fraud in health care are fragmented. Each payer

sees only a partial picture. This allows bad actors to move from program to program and to

exploit gaps in oversight.

(14) A single national payer for essential care, with a unified risk pool and claims platform, can

reduce waste, simplify administration, improve bargaining power, and stabilize coverage across

life events, while still allowing room for private supplemental options.

(15) Malpractice coverage and defensive medicine together represent a measurable share of

United States health care spending. Major reviews estimate that the combined costs of

malpractice premiums, litigation, and defensive medicine practices may account for between 2

and 3 percent of total health spending. This is roughly 100 billion to 150 billion dollars per year.

These costs fall unevenly on high risk specialties and do not always track clear gains in patient

safety.

(16) In many other developed systems, national malpractice rules combine three elements. Full

compensation of documented economic losses. Predictable limits on extreme noneconomic

awards. And strong incentives for providers to follow evidence based clinical guidelines.

(17) Predictable national malpractice rules that preserve full compensation for economic harm,

limit extreme noneconomic awards, and create safe harbors for adherence to evidence based

clinical standards issued by a transparent national board, can reduce defensive medicine and

premium spikes while preserving meaningful remedies for patients who experience preventable

harm.

(b) Purpose. The purpose of this Act is to

(1) establish a SAFECARE Plan that provides a universal floor of essential health coverage for

every legal resident, independent of employment or marital status,

(2) replace most existing basic health insurance arrangements with a single national payer for

essential care, financed through employer and employee payroll contributions and other

dedicated receipts, with declining reliance on transfers from general Federal revenues during

transition as provided in section 207,

(3) protect households from financial ruin due to illness through strict annual caps on out of

pocket costs and a program to redeem and cancel legacy medical debt,

(4) reform health workforce education costs through tuition caps, scholarships tied to service,

and structured loan forgiveness,

(5) consolidate data and enforcement authority to detect, prevent, and punish fraud and abuse,

(6) maintain a limited safety net for emergency and public health services for non members, for

the protection of the public,

(7) reform medical malpractice liability to stabilize provider costs, discourage defensive

medicine, and preserve patient access to fair compensation for real harm,

(8) reduce prescription drug and biologic prices through a national formulary and

most-favored-nation pricing linked to prices in comparable developed nations, and

(9) manage the transition from current arrangements to the SAFECARE Plan through a staged

schedule that preserves continuity of care.

In this Act:

(1) Secretary. The term Secretary means the Secretary of Health and Human Services.

(2) Plan. The term SAFECARE Plan or Plan means the program established under title I.

(3) Legal resident. The term legal resident means a citizen of the United States, a lawful

permanent resident, or an alien lawfully present in the United States, as defined by the Secretary

in regulations that are consistent with Federal immigration law.

(4) Plan member. The term Plan member means any legal resident enrolled in the Plan under title

III.

(5) Essential health services. The term essential health services means medically necessary

services that are included in the national benefit floor described in section 104.

(6) Provider. The term provider means any individual or entity that furnishes health services,

including hospitals, clinics, physicians, nurse practitioners, physician assistants, mental and

behavioral health professionals, dentists, optometrists, pharmacists, and allied health

professionals.

(7) Non member. The term non member means a person physically present in the United States

who is not a legal resident and is not enrolled as a Plan member, except as provided in the Bridge

option under section 603.

(8) Trust Fund. The term SAFECARE Trust Fund or Trust Fund means the fund established

under section 201.

(9) Income. The term income means adjusted gross income, as defined in the Internal Revenue

Code of 1986, with such modifications as the Secretary of the Treasury may prescribe for

purposes of this Act.

(10) Payroll. The term payroll means wages, salaries, and other compensation that are subject to

payroll tax under the Internal Revenue Code of 1986, including net earnings from self

employment.

(11) United States. The term United States includes the 50 States, the District of Columbia,

the Commonwealth of Puerto Rico, the United States Virgin Islands, Guam, American Samoa,

and the Commonwealth of the Northern Mariana Islands.

TITLE I. ESTABLISHMENT OF THE SAFECARE PLAN.

(a) Program. There is established within the Department of Health and Human Services a

program to be known as the SAFECARE Plan.

(b) Function. The Plan shall

(1) provide coverage for essential health services for all Plan members,

(2) pay participating providers for covered services, and

(3) coordinate with existing Federal, State, and private systems during the transition period set

forth in title X.

(a) Lead agency. The Secretary shall administer the Plan through the Centers for Medicare and

Medicaid Services or a successor agency designated by the Secretary.

(b) Advisory bodies. The Secretary may establish advisory councils on benefits, workforce,

payment policy, fraud control, medical liability, and other domains. These councils shall include

representatives of patients, providers, employers, and States.

(a) Entitlement. Every legal resident of the United States is entitled to enrollment in the Plan and

to coverage for essential health services, subject to the provisions of this Act.

(b) Nondiscrimination. Coverage and payment shall not vary because of health status, age, sex,

race, income, employment, marital status, or prior use of services.

(a) Benefit floor. The Plan shall cover, at a minimum, the following essential health services.

(1) Primary and preventive care, including routine office visits, screenings, and vaccinations.

(2) Specialty care and consultations.

(3) Emergency and trauma care.

(4) Inpatient and outpatient hospital services.

(5) Maternity, perinatal, and newborn care.

(6) Pediatric services, including basic dental and vision.

(7) Mental health and substance use disorder services, including outpatient and inpatient

treatment and medications.

(8) Rehabilitative and habilitative services and devices, including physical, occupational, and

speech therapy.

(9) Chronic disease management.

(10) Medically necessary diagnostic imaging and laboratory services.

(11) Medically necessary prescription drugs and biologics, subject to a national formulary and

the pricing requirements in section 405.

(12) Adult dental services and vision services, including routine preventive care and medically

necessary restorative or corrective services, under standards set by the Secretary.

(13) Long-Term Services and Supports. Medically necessary long-term care, including home- and

community-based services and custodial nursing facility care, subject to the same eligibility

standards previously applied under the Medicaid program.

(b) Preexisting conditions. The Plan shall not exclude or limit coverage of any essential health

service because such service is related to a preexisting condition.

(c) Supplemental services. The Secretary may define categories of non essential services that

may be offered as supplemental coverage, including elective cosmetic procedures, concierge

amenities, and similar items, provided that such services are not required for medical necessity.

(a) Prohibition on sale of duplicative basic coverage. No private health insurer or health benefit

plan may sell coverage that duplicates essential health services for Plan members.

(b) Scope of allowed private coverage. Private entities may sell supplemental coverage that

offers services or amenities beyond the essential benefit floor, such as private rooms, elective

cosmetic procedures, or reduced waiting times, so long as such coverage does not

(1) deny or delay access to essential services,

(2) condition access to essential services on purchase of supplemental coverage, or

(3) undermine the stability of the Plan risk pool.

(c) Enforcement. The Secretary and the Secretary of the Treasury shall enforce this section

through plan approval, tax rules, and civil monetary penalties.

(d) ERISA preemption and application to employee benefit plans. Notwithstanding section 514 of

the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1144), the provisions of this

Act shall apply to all employee benefit plans, including self-insured plans. No employer may

offer benefits duplicative of the Plan to avoid the contribution requirements of title II.

TITLE II. FINANCING AND THE SAFECARE TRUST FUND.

(a) Establishment. There is created in the Treasury a trust fund to be known as the SAFECARE

Trust Fund.

(b) Credits to the Trust Fund. The Trust Fund shall be credited with

(1) amounts equivalent to employer contributions required under section 202,

(2) amounts equivalent to employee and self employment contributions required under section

203,

(3) amounts transferred or credited from integrated Federal and State programs as provided in

title X, subject to section 207, and

(4) any other amounts appropriated to the Trust Fund.

(c) Expenditures. Amounts in the Trust Fund shall be available without fiscal year limitation for

(1) payment for essential health services furnished to Plan members,

(2) administration of the Plan,

(3) programs under titles V, VI, VII, VIII, and IX, and

(4) other activities authorized by this Act.

(a) In general. For each calendar year beginning on or after the main implementation date

specified in section 1103, every employer shall pay a National Health Employer Contribution

with respect to wages paid for payroll periods for individuals with respect to whom the

contribution under section 203 is in effect for such payroll periods, as determined under section

303(c).

(b) Standard rate. The standard contribution rate shall be 8.0 percent of wages described in subsection (a).

(c) Small employer rate. Congress may provide a reduced rate for employers with annual wages described in subsection (a)

below a threshold specified in law to protect small businesses.

(d) Replacement of private premiums. The contribution required under this section is intended to

replace employer expenditures on basic health insurance premiums. Employers shall not be

required to maintain separate basic coverage for essential services, but may offer supplemental

coverage as allowed under section 105.

(e) Anti-Avoidance Rule for Contract Labor.

(1) In general. For purposes of this section, the term "wages" includes covered contract remuneration.

(2) Covered contract remuneration defined. The term "covered contract remuneration" means remuneration paid by an employer to an individual for services performed as an independent contractor (as such status is reported for Federal tax purposes), if either of the following applies:

(A) Primary service dependence. More than 75 percent of the individual’s gross receipts from the performance of services during the taxable year (or during the most recent taxable year for which information is available, as specified by the Secretary of the Treasury) is attributable to such employer, including any person treated as the same employer under rules prescribed by the Secretary of the Treasury.

(B) Substantial control. The employer exercises substantial control over the manner and means by which the services are performed, under standards prescribed by the Secretary of the Treasury consistent with common law agency principles.

(3) Liability. In the case of covered contract remuneration, the employer shall be liable for the contribution under this section at the rate specified in subsection (b) with respect to such remuneration.

(4) Credit to contractor. The Secretary of the Treasury shall prescribe rules under which any amount paid by an employer under paragraph (3) with respect to covered contract remuneration shall be allowed as a credit to the individual receiving such remuneration against the portion of such individual’s liability under section 203 attributable to such remuneration. Any excess credit shall be treated as a payment of tax for purposes of section 203.

(a) In general. For each taxable year beginning on or after the main implementation date

specified in section 1103, each individual whose Plan coverage is effective under the phased

schedule in section 1005 shall pay an individual health contribution determined under this

section.

(b) Contribution Base and Modified Adjusted Gross Income. The contribution under this section

shall apply to the Modified Adjusted Gross Income of the individual for the taxable year,

determined on an individual basis.

(1) Modified Adjusted Gross Income defined. For purposes of this section, the term "Modified

Adjusted Gross Income" means adjusted gross income as defined in section 62 of the Internal

Revenue Code of 1986—

(A) Increased by:

(i) any tax-exempt interest received or accrued during the taxable year, and

(ii) the amount of any income from sources within United States territories (including Puerto

Rico, Guam, American Samoa, the Northern Mariana Islands, and the Virgin Islands) that is

excluded from gross income under section 933 of such Code or similar provisions, determined as

if such income were effectively connected with the conduct of a trade or business within the

United States.

(B) Reduced by:

(i) Qualified Business Income Deduction. An amount equal to the deduction allowed under

section 199A of such Code for the taxable year.

(ii) Social Security Benefits. Any amount received as benefits under title II of the Social Security

Act or tier 1 railroad retirement benefits which is included in gross income for the taxable year.

(iii) Veterans Benefits. Any amount received as benefits administered by the Department of

Veterans Affairs which is included in gross income for the taxable year.

(iv) Retirement Income Allowance. The aggregate amount of distributions from eligible

retirement plans (as defined in section 402(c)(8)(B) of such Code) and from individual

retirement plans (as defined in section 7701(a)(37) of such Code) included in gross income for

the taxable year, not to exceed the Retirement Exemption Limit.

(2) Retirement Exemption Limit.

(A) In general. The Retirement Exemption Limit shall be $100,000.

(B) Indexing. In the case of any taxable year beginning in a calendar year after 2026, the dollar

amount in subparagraph (A) shall be increased by an amount equal to—

(i) such dollar amount, multiplied by

(ii) the cost-of-living adjustment determined under section 1(f)(3) of the Internal Revenue Code

of 1986 for the calendar year in which the taxable year begins.

(c) Rate.

(1) Base individual rate. Except as provided in paragraph (2), the base individual health

contribution rate shall be 3.5 percent of Modified Adjusted Gross Income, applied from the

first dollar, with no minimum income threshold.

(2) Base self employed rate. In the case of net earnings from self employment, as determined

under section 1402(a) of the Internal Revenue Code of 1986, the base rate shall be 11.5

percent of such net earnings, applied from the first dollar, in lieu of the rate under paragraph

(1) on such net earnings.

(3) Additional surtax on high income. In addition to the base rate in this subsection, an

additional health surtax shall apply to Modified Adjusted Gross Income in the following

marginal brackets:

(A) 1.0 percent of Modified Adjusted Gross Income above 100,000 dollars.

(B) An additional 1.5 percent of Modified Adjusted Gross Income above 250,000 dollars.

(C) An additional 2.0 percent of Modified Adjusted Gross Income above 500,000 dollars.

(4) Additional self employed surtax. In addition to the base rate in paragraph (2), the

additional surtax in paragraph (3) shall apply to net earnings from self employment described

in paragraph (2) using the same marginal brackets.

(5) Indexing of thresholds. Beginning in calendar year 2031, the dollar thresholds in

paragraph (3) shall be adjusted not less than once every three years, based on growth in

median wages, under a methodology specified by the Secretary.

(d) Collection, estimated payments, and annual reconciliation.

(1) Withholding on wages. Employers shall withhold the base contribution under subsection

(c)(1) from wages paid to employees and remit such amounts to the Treasury in the same

manner as employment taxes are withheld and paid. Amounts withheld shall be treated as a

credit against the liability imposed by this section for the taxable year.

(2) Estimated payments on non wage income. Individuals with non wage income shall make

estimated tax payments consistent with section 6654 of the Internal Revenue Code of 1986,

as prescribed by the Secretary of the Treasury, to avoid material underpayment.

(3) Annual reconciliation. The Secretary of the Treasury shall prescribe regulations to

reconcile amounts withheld and estimated payments against the total liability under this

section on the individual's annual Federal income tax return.

(e) Replacement of private premium payments. The individual health contribution is intended

to replace private expenditures on basic health insurance premiums and deductibles for

essential care.

AND ANNUAL CAPS.

(a) No deductibles and no coinsurance. The Plan shall not impose deductibles or coinsurance for

essential health services. Any point of service cost sharing under this section shall be in the form

of fixed copayments only.

(b) Children and low income individuals. Plan members who are under age 18, and Plan

members with individual modified adjusted gross income, as defined in section 203(b), below

200 percent of the Federal poverty level applicable to a single individual, shall receive essential

health services with no point of service copayments.

(c) Standard copayments. For Plan members not described in subsection (b), the Secretary may

establish modest fixed copayments for certain non emergency services, subject to the annual cap

in subsection (d). The Secretary shall design copayments to avoid discouraging preventive care

and clinically indicated treatment.

(d) Annual cap.

(1) In general. Each Plan member shall have a fixed annual cap on total point of service

copayments for essential health services.

(2) Initial cap. The initial cap shall be 750 dollars per person per year in 2026 dollars.

(3) Indexing. The cap shall be indexed annually to growth in median wages, under a

methodology specified by the Secretary.

(4) After cap reached. After the cap is reached for a member, the Plan shall pay 100 percent of

covered essential health services for that member for the rest of the year.

(e) Per person rule. The cap applies per individual and shall not increase due to marriage,

household composition, or enrollment of dependents.

TAXES AND COORDINATION WITH EXISTING FEDERAL HEALTH REVENUES.

(a) Replacement of Hospital Insurance payroll taxes. Beginning on the main implementation

date, the Hospital Insurance portion of employment taxes under the Internal Revenue Code of

1986 shall be reduced to 0 percent for wages and self employment income that are subject to

contributions under sections 202 and 203 of this Act.

(b) Conforming amendments to Internal Revenue Code of 1986.

(1) Employee Hospital Insurance tax. Section 3101(b) of the Internal Revenue Code of 1986

is amended by adding at the end the following new paragraph:

"(3) Coordination with SAFECARE Plan. In the case of wages received by an individual with

respect to whom the contribution under section 203 of the Secure Affordable Federal Essential

Care Act is in effect for the payroll period, the rate of tax under subsection (b)(1) shall be

0 percent."

(2) Employer Hospital Insurance tax. Section 3111(b) of the Internal Revenue Code of 1986

is amended by adding at the end the following new paragraph:

"(3) Coordination with SAFECARE Plan. In the case of wages paid to an individual with

respect to whom the contribution under section 203 of the Secure Affordable Federal Essential

Care Act is in effect for the payroll period, the rate of tax under subsection (b)(1) shall be

0 percent."

(3) Self employment Hospital Insurance tax. Section 1401(b) of the Internal Revenue Code of

1986 is amended by adding at the end the following new paragraph:

"(3) Coordination with SAFECARE Plan. In the case of self employment income of an

individual with respect to whom the contribution under section 203 of the Secure Affordable

Federal Essential Care Act is in effect for the taxable year, the rate of tax under subsection

(b)(1) shall be 0 percent."

(c) Coordination with remaining Federal health revenues. Beginning on the first day of the first

calendar year that starts at least two years after the date of enactment, specified portions of other

existing Federal health related tax revenues and program receipts, as determined by Congress,

may be credited to the Trust Fund, subject to section 207.

(d) Consolidation of program budgets. As programs are integrated into the Plan under title X,

their budget authority for essential health services shall be consolidated into the Trust Fund.

(e) No double payroll charge. It is the intent of Congress that, beginning on the main

implementation date, the employer and employee Hospital Insurance payroll tax is replaced by

the contributions under sections 202 and 203, and is not imposed in addition to them.

(f) Repeal of Net Investment Income Tax.

(1) In general. Section 1411 of the Internal Revenue Code of 1986 (imposing a tax on net

investment income) is repealed.

(2) Effective date. The repeal made by this subsection shall apply to taxable years beginning on

or after the main implementation date described in section 1103(b).

ADJUSTMENTS.

(a) Purpose. The purpose of this section is to maintain a stable Trust Fund reserve sufficient to address

unexpected costs and economic fluctuations, without deficit financing.

(b) Reserve target band. The Secretary shall administer the Trust Fund to maintain a reserve ratio within a

target band of not less than 5 percent and not more than 10 percent.

(c) Reserve ratio defined. For purposes of this section, the term "reserve ratio" means the ending Trust

Fund balance for a fiscal year divided by projected Trust Fund outlays for the immediately following

fiscal year, as determined by the Chief Actuary of the Centers for Medicare and Medicaid Services.

(d) Automatic upward adjustment. If the Chief Actuary determines that the reserve ratio for a fiscal year

is below 5 percent, then for the following calendar year the rates under sections 202 and 203 shall be

increased as follows:

(1) Employer rate increase. The rate in section 202(b) shall increase by 0.20 percentage points.

(2) Base individual rate increase. The base employee rate in section 203(c)(1) shall increase by 0.10

percentage points.

(3) Base self employed rate increase. The base self employed rate in section 203(c)(2) shall increase by

0.30 percentage points.

(4) Surtax rate increase. Each additional surtax rate in section 203(c)(3) shall increase by 0.10 percentage

points, and the corresponding surtax rates applied under section 203(c)(4) shall increase by the same

amount.

(e) Automatic downward adjustment. If the Chief Actuary determines that the reserve ratio for a fiscal

year is above 10 percent, then for the following calendar year the rates under sections 202 and 203 shall

be decreased as follows:

(1) Employer rate decrease. The rate in section 202(b) shall decrease by 0.20 percentage points.

(2) Base individual rate decrease. The base employee rate in section 203(c)(1) shall decrease by 0.10

percentage points.

(3) Base self employed rate decrease. The base self employed rate in section 203(c)(2) shall decrease by

0.30 percentage points.

(4) Surtax rate decrease. Each additional surtax rate in section 203(c)(3) shall decrease by 0.10 percentage

points, and the corresponding surtax rates applied under section 203(c)(4) shall decrease by the same

amount.

(f) Annual adjustment limits. In any single year, the total adjustment under subsection (d) or (e) and under

section 207(e)(3) shall not exceed:

(1) 0.60 percentage points for the employer rate,

(2) 0.30 percentage points for the base employee rate and any surtax rate adjustments under paragraphs

(d)(4) and (e)(4), and

(3) 0.90 percentage points for the base self employed rate.

(g) Notice and publication. Not later than November 15 of each year, the Secretary shall publish in the

Federal Register the reserve ratio determination and any rate adjustments for the following year.

(h) Congressional override. Congress may override an automatic adjustment for a year by enactment of a

law that expressly provides an alternative rate schedule for that year.

CONVERGENCE.

(a) Purpose. The purpose of this section is to reduce reliance on transfers from general Federal

revenues, to strengthen long term fiscal sustainability, and to ensure that universal essential

coverage is funded primarily through dedicated receipts.

(b) Definitions. In this section:

(1) Dedicated receipts. The term dedicated receipts means amounts credited to the Trust Fund

from employer and employee contributions under sections 202 and 203, self employment

contributions under section 203, copayments collected under section 204, civil monetary

penalties, recoveries, and recoupments under this Act, and other receipts that are permanently

dedicated to the Trust Fund by law.

(2) General Fund transfer. The term General Fund transfer means any amount appropriated or

transferred to the Trust Fund from the general fund of the Treasury or from other general revenue

accounts that are not dedicated receipts.

(c) Limitation on General Fund transfers.

(1) Transition limitation schedule. For each fiscal year of the Trust Fund beginning on or after

the main implementation date, General Fund transfers shall not exceed the following percentages

of total Trust Fund outlays for that fiscal year:

(A) For the first and second such fiscal years, 20 percent.

(B) For the third and fourth such fiscal years, 10 percent.

(C) For the fifth and sixth such fiscal years, 5 percent.

(D) For the seventh and eighth such fiscal years, 2 percent.

(E) For the ninth such fiscal year and each fiscal year thereafter, 0 percent.

(2) Rule of construction. Nothing in this subsection limits the crediting of dedicated receipts to

the Trust Fund.

(d) Temporary advances during recession or public health emergency.

(1) In general. If the Secretary determines that a recession has been declared by the National

Bureau of Economic Research, or that a national public health emergency has been declared

under Federal law, the Secretary may request a temporary advance to the Trust Fund from

general Federal revenues in excess of the applicable limitation under subsection (c).

(2) Repayment. Any advance under paragraph (1) shall be repaid to the general fund of the

Treasury from dedicated receipts not later than the end of the third fiscal year after the advance is

made.

(3) Limit. The total amount of outstanding advances under this subsection shall not exceed 0.5

percent of gross domestic product, as most recently published by the Bureau of Economic

Analysis.

(e) Compliance mechanism and corrective actions.

(1) Annual projection. Not later than November 15 of each year, the Chief Actuary shall publish

a projection of the amount of General Fund transfers, if any, that would be required to maintain

Plan operations for the following fiscal year.

(2) Required corrective actions. If the projection under paragraph (1) indicates that General Fund

transfers would exceed the limitation under subsection (c) for the following fiscal year, the

Secretary shall implement corrective actions in the following order, to the extent practicable:

(A) Strengthen enforcement of prescription drug and biologic pricing requirements under section

405, including tighter review of exceptions under section 405(f).

(B) Reduce administrative cost and denial friction through actions under sections 403, 404, and

804, including simplification of documentation and standardized billing rules.

(C) Adjust payment policy within the guardrails of section 402, including site of service rules,

payment methods that reward value, and targeted updates that protect rural and safety net access.

(3) Dedicated funding convergence adjustment. If the Secretary determines, after implementing

corrective actions under paragraph (2), that General Fund transfers would still exceed the

limitation under subsection (c), then for the following calendar year the rates under sections 202

and 203 shall be increased by the amounts described in section 206(d), and may be increased in

subsequent years until the projected General Fund transfers are within the applicable limitation.

Such adjustments shall be subject to the annual limits in section 206(f).

(f) Cost growth discipline.

(1) Benchmark. The Secretary shall administer the Plan to limit the growth rate of average Trust

Fund outlays per Plan member to a benchmark equal to the growth rate of nominal gross

domestic product per capita, as most recently published by the Bureau of Economic Analysis.

(2) Corrective action. If the Chief Actuary determines that projected outlay growth exceeds the

benchmark, the Secretary shall publish a corrective plan that prioritizes actions under subsection

(e)(2) before reliance on contribution rate increases.

(g) Reports. Not later than 180 days after the end of each fiscal year, the Secretary shall submit

to Congress a report describing progress toward reducing reliance on General Fund transfers and

compliance with the schedule in subsection (c).

TITLE III. ELIGIBILITY, ENROLLMENT, AND CONTINUITY.

(a) Full Plan members. Every legal resident of the United States is eligible to be a full Plan

member.

(b) Non members. Non members are not Plan members, except as provided for the Bridge option

in section 603.

(a) Procedures. The Secretary shall establish procedures to automatically enroll legal residents as

Plan members, using existing Federal and State records such as Social Security, immigration,

and tax records.

(b) No opt out of essential floor. Beginning on the date that a legal resident becomes eligible for automatic enrollment under

the phase-in schedule in section 1005, such resident may not opt out of the essential benefit

floor, although a resident may decline optional supplemental features.

(c) Federal Bypass Authority.

(1) State cooperation option. A State may elect to provide data necessary for enrollment under subsection (a). In exchange for such cooperation, the State shall receive administrative coordination payments under section 1006, in amounts and under standards specified by the Secretary.

(2) Federal default. If a State elects not to provide such data under paragraph (1), or fails to provide such data within 30 days after the start of an enrollment period specified by the Secretary, the Secretary shall execute enrollment for residents of such State using exclusively Federal data sources, including data from the Internal Revenue Service, the Social Security Administration, the Department of Homeland Security, and such other Federal sources as the Secretary determines appropriate.

(3) Consequence. A State declining cooperation under paragraph (1) shall be ineligible for the administrative coordination payments described in that paragraph for the period of noncooperation.

(a) Plan identifier. Each Plan member shall be assigned a unique Plan identifier. The Secretary

may use an existing Federal identifier if appropriate.

(b) Privacy. The Secretary shall maintain secure electronic records of enrollment and claims.

Health data shall be protected by privacy laws and shall not be used for immigration enforcement

or non health purposes.

(c) Employer payroll status verification.

(1) System. The Secretary, in coordination with the Secretary of the Treasury, shall establish a

secure electronic verification mechanism for employers.

(2) Function. An employer may submit the name and Taxpayer Identification Number of an

employee to query whether such employee is currently subject to the contribution requirements of

section 203 for the payroll period.

(3) Response. The system shall return a single binary response indicating whether the SAFECARE

contribution applies. The system shall not disclose the underlying reason.

(4) Safe harbor. An employer who relies on a response from this system in good faith to determine

withholding and remittances under sections 202, 203, and 205 shall not be liable for underpayment

penalties related to such determination.

CERTIFICATION.

(a) Claims and enrollment systems. The Secretary shall develop and deploy the enrollment,

eligibility verification, claims intake, claims adjudication, payment, and program integrity

systems necessary to administer the Plan.

(b) Incremental deployment. The Secretary shall deploy Plan systems in phases, including pilots

and regional rollouts, to ensure continuity of care and to reduce implementation risk.

(c) Independent certification of readiness.

(1) In general. Not later than 180 days before the start of automatic enrollment under section

1005(b), 1005(c), 1005(d), or 1005(e), as applicable to the affected phase, the Secretary shall obtain an independent certification that core enrollment and claims

systems are capable of operating at scale.

(2) Certifying entities. The certification shall be performed by the Inspector General of the

Department of Health and Human Services, in consultation with the Government Accountability

Office, or by an independent entity designated by them.

(3) Criteria. Certification shall assess at minimum:

(A) cybersecurity and privacy controls,

(B) identity and eligibility matching accuracy,

(C) claims throughput and payment timeliness,

(D) error rates and appeals handling capacity,

(E) disaster recovery and continuity planning, and

(F) interoperability with State and Federal data sources required for enrollment and coordination.

(d) Contingency authority.

(1) If certification under subsection (c) is not obtained, the Secretary shall delay the affected

phase of automatic enrollment for not more than 12 months and shall implement a corrective

action plan.

(2) During any such delay, individuals shall retain existing coverage and protections, and the

Secretary shall prioritize enrollment of uninsured individuals and individuals in integrated

Federal programs for whom readiness is certified.

(e) Transparency.

(1) Public dashboard. The Secretary shall maintain a public dashboard reporting implementation

progress, major milestones, system performance metrics, and independent audit findings.

(2) Reports. Not later than 90 days after enactment and every 180 days thereafter until full

implementation, the Secretary shall submit to Congress a report describing progress, risks, and

mitigation steps.

(a) Independence from employment. Plan membership shall not terminate or change solely

because a member gains or loses employment, changes employers, or changes hours.

(b) Independence from residence within United States. Plan membership shall remain in force

when a member moves from one State to another within the United States.

TITLE IV. PROVIDER PARTICIPATION, PAYMENT, AND PRESCRIPTION DRUG.

PRICING

(a) Requirement. A provider that seeks payment from the Plan shall enter into a participation

agreement with the Secretary.

(b) Terms. The agreement shall require the provider to

(1) accept Plan payment as payment in full for essential health services, subject to authorized

copayments,

(2) comply with Plan billing standards and data reporting requirements,

(3) comply with nondiscrimination and access standards, and

(4) cooperate with audits and fraud control activities.

(c) Prohibition on excess charges.

(1) In general. No provider, whether participating in the Plan or not, may

charge or collect from a Plan member an amount for an essential health

service that exceeds the payment rate established under section 402 for

that service.

(2) Penalty. Any violation of paragraph (1) shall result in a civil monetary

penalty equal to 3 times the amount of the excess charge, in addition to

any other remedies available under Federal or State law.

(a) Methods. The Plan may pay providers using fee schedules, bundled payments, global

budgets, capitation, or other methods that support access, quality, and cost control.

(b) Rate setting. Payment rates shall be set in a transparent manner. The Secretary shall consider

(1) the reasonable costs of efficient providers,

(2) the need to maintain access in rural and underserved areas, and

(3) the overall financial condition of the Trust Fund.

(c) Minimum payment floors.

(1) In general. For essential health services furnished on or after the main implementation date,

the Secretary shall set national base rates that are not less than the following percentages of the

corresponding Medicare payment amounts for the same or comparable services, as determined

by the Secretary:

(A) Inpatient hospital services: 100 percent.

(B) Outpatient hospital services: 100 percent.

(C) Physician and practitioner professional services: 100 percent.

(D) Clinical laboratory services: 100 percent.

(E) Imaging and diagnostics paid under fee schedules: 100 percent.

(F) Skilled nursing facility and home health services: 100 percent.

(2) Geographic adjustments. The Secretary shall apply geographic adjustments and special add

on payments to preserve access in high cost urban areas and in rural and frontier areas.

(3) Site neutrality. The Secretary shall ensure that payment rates for essential health services

are consistent across sites of service. A service provided in a hospital outpatient department

shall be paid at the same rate as the same service provided in a physician office or

freestanding clinic, unless the Secretary determines that clinical acuity requires a higher

facility fee.

(4) Transitional Rate Corridor.

(A) Years 3 through 5. During the first three calendar years of Plan operations beginning on the main implementation date, the Secretary shall apply a transition multiplier to the rates established under this subsection for acute care hospitals.

(B) Multiplier. The transition multiplier shall be 120 percent of the Medicare rate in the first such calendar year, 110 percent in the second such calendar year, and 105 percent in the third such calendar year.

(C) Convergence. Beginning with the fourth calendar year of Plan operations, the rate shall be 100 percent as specified in paragraph (1).

(d) Rural and essential access stability.

(1) Mandatory global budgets. The Secretary shall establish a Global Budget Payment Model for:

(A) Critical Access Hospitals, as defined in section 1861(mm)(1) of the Social Security Act.

(B) Rural hospitals with fewer than 50 beds, as determined by the Secretary.

(C) Sole Community Hospitals, as defined in section 1886(d)(5)(D)(iii) of the Social Security Act.

(2) Methodology. The Global Budget shall be set to cover the allowable operating costs of the

facility plus a stable growth factor tied to local health needs, under a methodology specified by

the Secretary that is decoupled from service volume.

(3) Effect. Facilities paid under this subsection shall be paid under the Global Budget model and

shall not be subject to payment limitations under subsection (c)(3) that would materially impair

their solvency or access obligations.

(4) Access protection. The Secretary shall ensure that payment methods under this section do not

cause unreasonable reductions in access to emergency services, maternity services, trauma

services, burn services, neonatal intensive care, or essential specialty services in any region.

(e) Annual access review.

(1) Review. The Secretary shall conduct an annual access review by region and by specialty.

(2) Corrective action. If the review finds a material access shortage attributable to payment rates,

the Secretary shall implement corrective adjustments within 180 days.

(a) Standard billing format. The Secretary shall adopt a single standard electronic billing format

for claims for essential health services.

(b) Surprise billing ban. A provider may not bill a Plan member for amounts above authorized

copayments for covered essential services.

The Secretary shall design billing, documentation, and reporting requirements to minimize the

time that providers spend on administrative tasks that do not contribute to patient care, consistent

with fraud prevention and program integrity.

MOST-FAVORED-NATION PRESCRIPTION DRUG PRICING.

(a) National formulary authority. The Secretary shall establish and maintain a national formulary

for prescription drugs and biologics covered as essential health services.

(b) Negotiated net price requirement. As a condition of coverage on the formulary, a

manufacturer shall agree to provide the drug or biologic to the Plan at a negotiated net price.

(c) Most-favored-nation ceiling. The negotiated net price for a formulary drug or biologic shall

not exceed the International Reference Price for that drug or biologic, except as provided in

subsection (f).

(d) International Reference Price defined. The term International Reference Price means the

lowest net price, net of all rebates, discounts, chargebacks, and other price concessions, available

for the same drug, strength, and dosage form in any member country of the Organisation for

Economic Co-operation and Development with gross domestic product per capita not less than

60 percent of that of the United States, as determined by the Secretary.

(e) Data reporting and audit.

(1) Reporting. Manufacturers shall report to the Secretary the net prices described in subsection

(d) in such form as the Secretary shall require.

(2) Audit and penalties. Such reporting shall be subject to audit. A manufacturer that materially

misreports prices or concessions shall be subject to civil monetary penalties and other remedies

as provided by law.

(f) Limited exception for access.

(1) In general. The Secretary may temporarily permit a negotiated net price above the

International Reference Price only if the Secretary makes a written determination, published in

the Federal Register, that

(A) the drug or biologic has no clinically appropriate therapeutic alternative for the indicated use,

and

(B) failure to grant the exception would likely cause significant and immediate harm to patient

access.

(2) Duration. Any exception under this subsection shall be limited to not more than 24 months

and may be renewed only upon a new written determination.

(g) Enforcement. If a manufacturer declines to comply with this section, the Secretary may

exclude the drug or biologic from the formulary and may impose alternative payment limits or

other remedies as authorized by law.

(h) Fail-Safe Pricing.

(1) Trigger. If the Secretary determines that an International Reference Price is not available for a formulary drug or biologic, including because the drug or biologic is not marketed in countries used to determine such International Reference Price, then the negotiated net price under subsection (b) shall be subject to paragraph (2).

(2) Maximum negotiated net price. In a case described in paragraph (1), the negotiated net price shall not exceed the sum of:

(A) Comparator price. The negotiated net price of the most clinically comparable therapeutic alternative, as determined by the Secretary, or if such negotiated net price is not available, the applicable Plan payment limit for such alternative as determined by the Secretary, and

(B) Value-based premium. A value-based premium reflecting incremental clinical benefit, as determined by the Institute for Clinical and Economic Review (ICER) or a successor, or by a similar independent value assessment body designated by the Secretary, under methods specified by regulation.

(3) Implementation. The Secretary shall prescribe rules to prevent evasion of this subsection through product relabeling, dosage-form manipulation, or delayed international marketing designed primarily to avoid the availability of an International Reference Price.

TITLE V. HEALTH WORKFORCE AND EDUCATION REFORM.

(a) Condition on Federal participation. Any educational institution that

(1) receives Federal research funds, or

(2) is eligible for Federal student loan programs, or

(3) receives Plan payments for clinical training

and that offers health professions programs covered by this title, shall comply with tuition caps.

(b) Caps. The Secretary, in consultation with the Secretary of Education, shall set maximum

annual tuition amounts. For example

(1) for medical degree programs leading to MD or DO, a cap of not more than 15,000 dollars per

academic year in 2026 dollars, and

(2) for core nursing and allied health programs, a cap of not more than 10,000 dollars per

academic year in 2026 dollars.

(3) Non-application to non-residents. The tuition caps under this section shall

not apply to students who are not legal residents, as defined in section 4, or

who are studying under a non-immigrant student visa. Institutions may

charge such students market rates.

The caps shall be indexed annually to a health education cost index defined by regulation.

(c) Non compliant institutions. An institution that does not comply with the caps shall be

ineligible for the Federal funds and Plan payments described in subsection (a), and its students

shall be ineligible for the grant and service scholarship programs under section 502.

(d) Coordination with education support payments. The Secretary shall implement tuition caps

under this section together with the Health Professions Education Support Payments under

section 501A to prevent disruption of training capacity.

(e) Accreditation protection.

(1) Federal financial responsibility. The Secretary shall deem any institution

receiving Health Professions Education Support Payments under section 501A

as having satisfied applicable Federal financial responsibility standards for

purposes of participation in Federal student aid programs, as determined by

the Secretary in consultation with the Secretary of Education.

(2) Accreditor limitation. The Secretary of Education shall prohibit any

accrediting agency recognized by the Department of Education from

withdrawing accreditation solely on the basis of revenue reductions resulting

from compliance with this section.

(f) Domestic priority.

(1) Reservation of seats. As a condition of Federal participation under

subsection (a), not less than 90 percent of the incoming class seats in any

health professions program covered by this title shall be reserved for legal

residents of the United States.

(2) Reporting. Each covered institution shall report annually to the Secretary

and the Secretary of Education the number of incoming seats offered and

filled by legal residents and non-residents, under a methodology specified

by regulation.

(a) In general. The Secretary, in consultation with the Secretary of Education, shall make Health

Professions Education Support Payments to eligible institutions to ensure that tuition caps under

section 501 do not reduce the ability of such institutions to provide high quality education and

clinical training.

(b) Eligible institutions. An institution is eligible if it complies with tuition caps under section

501 and participates in the clinical training and workforce goals of this title.

(c) Amount.

(1) Base formula. The Secretary shall pay an amount equal to the difference between

(A) allowable educational costs per student as determined under regulations, and

(B) capped tuition and mandatory fees collected per student under section 501.

(2) Guardrails. Allowable costs shall exclude excessive executive compensation, non educational

real estate expansion, and unrelated administrative growth as defined by regulation.

(d) Performance conditions. Payments under this section shall be conditioned on measurable

outcomes, including graduation rates, board or licensure pass rates, and placement into priority

specialties or priority service areas.

(e) Anti gaming. The Secretary shall audit institutions for cost inflation and shall reduce or

recoup payments for unreasonable cost growth.

(a) Grants. The Secretary shall provide grants to eligible students in approved health professions

programs to cover tuition up to the caps and reasonable education related expenses.

(b) Service obligation. As a condition of receiving grants, a student shall agree to serve for a

period of not less than five years and not more than seven years in Plan covered roles. Priority

shall be given to service in primary care, rural and frontier areas, and underserved urban

communities, and in high need specialties such as psychiatry and emergency medicine.

(a) Establishment. The Secretary shall establish a Workforce Relief Loan Forgiveness Program

to provide forgiveness of qualifying educational loans for existing health professionals.

(b) Amount. For each year of full time qualifying service in designated roles or areas, a

participant shall receive forgiveness of a fixed amount of outstanding principal. For example,

30,000 dollars per year for physicians and 15,000 dollars per year for nurses and allied

professionals, up to a maximum of ten years.

(c) Focus. The Secretary shall focus the Program on professionals with high debt burdens and on

areas with shortages of providers.

(d) Tax treatment. Notwithstanding any other provision of law, the discharge

of any loan liability under this section shall not be included in the gross

income of the participant for purposes of the Internal Revenue Code of 1986.

The Secretary shall define and update a list of priority geographic areas and specialties based on

access, outcomes, and workforce data. Scholarship and loan forgiveness incentives shall be

targeted to these priorities.

TITLE VI. NON MEMBER CARE AND SAFETY NET.

(a) Establishment. Within the Trust Fund there is established an account to be known as the

Safety Net Care Fund.

(b) Use. The Safety Net Care Fund shall be used to reimburse providers for services described in

sections 602 and 603.

(c) Transitional stop-loss payments.

(1) Authority. During the first 5 years of Plan operations, the Secretary shall make quarterly

stop-loss payments to Tier 1 Safety Net Hospitals, as designated by the Secretary under

regulations.

(2) Trigger. A stop-loss payment shall be made if the facility demonstrates that Plan revenues

under title IV are insufficient to cover the direct costs of providing emergency, trauma, burn, or

neonatal intensive care.

(3) Condition. As a condition of receipt, the facility shall submit a corrective action plan to

improve operational efficiency without cutting clinical staff.

PUBLIC HEALTH PRIMARY CARE SERVICES FOR NON MEMBERS.

(a) Required services. Hospitals and other designated providers shall furnish to any person

physically present in the United States, regardless of status or ability to pay,

(1) emergency stabilizing care,

(2) essential maternity and newborn care,

(3) diagnosis and treatment of serious contagious diseases, and

(4) limited public health primary care, including screening, vaccination, and outpatient diagnosis

and treatment for communicable diseases of public health concern and related primary care

services necessary to prevent transmission, as defined by the Secretary.

(b) Reimbursement. The Plan shall reimburse providers for such services through the Safety Net

Care Fund at rates established by the Secretary.

(a) Bridge coverage. The Secretary may establish a Bridge tier of limited coverage that allows

certain long term non citizens, including some non members with at least five years of proven

residence and tax compliance, to buy into or receive subsidized coverage that is less than full

Plan membership but that includes preventive and primary care.

(b) Firewall. Health data gathered under the Plan and the Bridge option shall not be shared with

immigration enforcement authorities, except as ordered by a court for a criminal investigation

unrelated to civil immigration violations.

(c) Clarification. Nothing in this section shall be construed to limit required services under

section 602(a)(4).

(a) Establishment. The Secretary shall establish a Capital Grant Program to fund facility

modernization and medical technology acquisition.

(b) Funding structure.

(1) Sustainment block grants. For each fiscal year, the Secretary shall distribute 50 percent

of amounts authorized under subsection (d) via formula to participating hospitals for routine

facility maintenance, IT security upgrades, and replacement of clinical equipment at end of

life.

(2) Strategic innovation grants. For each fiscal year, the Secretary shall distribute 50 percent

of amounts authorized under subsection (d) via competitive grants for

(A) acquisition of advanced medical technology, including robotic surgery systems and

advanced imaging,

(B) construction of new clinical capacity in underserved areas, including behavioral health

and emergency capacity, and

(C) telehealth infrastructure modernization and related secure clinical networking.

(c) Prohibition on non clinical spend. Grant funds shall strictly exclude spending on executive

administration buildings, marketing assets, atriums, or aesthetic landscaping.

(d) Funding. There are authorized to be appropriated from the Trust Fund 100,000,000,000

dollars for each fiscal year to carry out this section. Such amount shall be indexed annually to

the Producer Price Index for construction, as published by the Bureau of Labor Statistics,

under a methodology specified by the Secretary.

TITLE VII. MEDICAL DEBT REDEMPTION.

(a) Establishment. The Secretary shall establish a Medical Debt Redemption Facility within the

Department of Health and Human Services.

(b) Funding and authority.

(1) In general. For each of the first 10 fiscal years beginning on or after the main implementation

date, there are authorized to be transferred from the Trust Fund to the Facility not less than

5,000,000,000 dollars and not more than 15,000,000,000 dollars per year, as needed to meet the

objectives of this title.

(2) Purchasing efficiency goal. The Facility shall seek to acquire eligible medical debt at the

lowest feasible cost as measured by cents paid per dollar of face value, consistent with

verification and consumer protections.

(3) Report. Not later than 180 days after the end of each fiscal year, the Secretary shall submit a

report to Congress stating

(A) total face value acquired,

(B) total price paid,

(C) average cents per dollar paid,

(D) total debt cancelled, and

(E) remaining estimated stock of eligible medical debt.

(c) Objective. The Facility shall prioritize actions intended to eliminate the majority of eligible

legacy medical debt within the first 10 fiscal years, subject to availability of portfolios for

purchase at reasonable market prices.

(a) Authority to acquire. The Facility may purchase portfolios of medical debt at fair market

value from providers, collectors, and debt buyers.

(b) Priority. The Facility shall give priority to portfolios that

(1) consist mainly of debt owed by individuals with individual income below or near the national

median individual income, or

(2) involve older debts, or

(3) have already been sold for collection at a deep discount.

(c) Cancellation. Debt acquired under this section shall be cancelled. No person may attempt to

collect such debt.

The Secretary shall ensure that

(1) affected individuals are notified of cancellation in clear language, and

(2) credit reporting agencies update records to reflect that such debt has been forgiven and shall

not be reported as active debt.

TITLE VIII. FRAUD, WASTE, AND ABUSE CONTROLS.

(a) Establishment. The Secretary shall create a National Health Claims Data Platform to receive,

store, and analyze claims data for services funded under this Act.

(b) Standards. The Secretary shall establish uniform data and transaction standards and shall

require participating providers and contractors to submit claims in accordance with those

standards.

(a) Analytics. The Secretary shall implement analytic systems, including statistical and machine

learning methods, to identify anomalous billing patterns in near real time.

(b) Pre payment review. The Secretary may withhold payment of claims that are flagged as high

risk until a review is completed.

(a) Offense. Any person who knowingly executes or attempts to execute a scheme to defraud the

Plan or the Trust Fund in an amount that exceeds 100,000 dollars in any twelve month period

commits a Federal offense.

(b) Penalties. The offense shall be punishable by imprisonment, fines, and mandatory forfeiture

of property derived from the offense, in a manner similar to penalties for major health care fraud

and wire fraud under existing law.

ADVANCED ANALYTICS AND AI.

(a) Establishment. The Secretary shall establish a continuous performance monitoring program

for the SAFECARE Plan, to be known as the National Health Integrity, Efficiency, and Value

Program.

(b) Purpose. The purposes of the Program are to

(1) detect and reduce fraud, waste, and abuse,

(2) measure and reduce administrative burden,

(3) identify high value care and low value care patterns,

(4) improve payment accuracy and timeliness,

(5) monitor access, quality, and outcomes, and

(6) support evidence based benefit design and clinical standards over time.

(c) Use of advanced analytics and AI tools. The Secretary shall deploy modern analytic tools,

including state of the art statistical methods and machine learning or AI systems, to support the

purposes in subsection (b), subject to the safeguards in this section.

(d) Required system capabilities. The Program shall include, at minimum, capabilities to

(1) produce real time dashboards for claims flow, payment timeliness, denial rates, appeal rates,

provider participation, and member access metrics,

(2) identify abnormal billing patterns and network level anomalies,

(3) estimate administrative cost and time burdens on providers and reduce such burdens through

simplified rules, standardized documentation, and automation where appropriate,

(3A) provider burden reduction accountability. The Secretary shall measure and publish, on not

less than an annual basis, objective indicators of administrative burden on participating

providers, including estimated hours spent on billing, documentation, prior authorization, and

appeals, and shall publish year over year changes in such indicators and the specific rule or

system changes responsible for reductions,

(4) monitor utilization and outcomes to identify low value or duplicative services and

opportunities for prevention,

(5) measure the impact of payment policy changes on rural, frontier, and safety net access, and

(6) support program integrity actions under section 802 while minimizing improper denials and

delays.

(e) Human review and due process. The Secretary shall ensure that

(1) any adverse action triggered by analytic or AI systems, including a payment hold, denial,

recoupment, or referral for investigation, is subject to human review before final action, except

for automated holds of limited duration for clearly defined high risk patterns as determined by

regulation,

(2) providers and Plan members have access to a timely appeals process with clear explanations

of the basis for the action, and

(3) the use of analytic tools does not create unreasonable barriers to medically necessary care.

(f) Transparency and reporting.

(1) Public reporting. Not later than 18 months after the main implementation date, and annually

thereafter, the Secretary shall publish a performance report describing Plan performance on key

metrics, including fraud recoveries, improper payment rates, administrative burden measures,

access measures, and outcome measures.

(2) Model transparency. The Secretary shall publish plain language descriptions of the categories

of signals and factors used by analytic systems for fraud detection and payment integrity, while

protecting sensitive enforcement details.

(g) Model governance and audits.

(1) Governance. The Secretary shall establish model governance requirements, including

documentation of training data sources, validation methods, change control, and ongoing

monitoring for model drift.

(2) Independent audit. The Inspector General of the Department of Health and Human Services

shall conduct periodic audits of the Program, including review of accuracy, error rates, improper

denials, and compliance with subsection (e).

(3) Bias and fairness testing. The Secretary shall test analytic systems for disparate impacts on

protected classes and on underserved communities, and shall mitigate identified issues through

model adjustments and policy controls.

(h) Privacy and use limitations. Data and analytic outputs under this section shall be used only

for health program administration, payment integrity, quality improvement, and public health

functions authorized by this Act. Such data shall not be used for immigration enforcement or non

health purposes.

(i) Cybersecurity. The Secretary shall implement cybersecurity controls consistent with Federal

standards and shall conduct regular security testing of systems used under this section.

(j) Authorization of appropriations. There are authorized to be appropriated from the Trust Fund

such sums as may be necessary to carry out this section, including procurement of analytic

tooling, staffing, independent evaluation, and security measures.

TITLE IX. MEDICAL LIABILITY AND MALPRACTICE REFORM.

(a) Purpose. The purpose of this title is to

(1) preserve meaningful remedies and full recovery of documented economic losses for patients

who suffer injury as a result of substandard care,

(2) stabilize and reduce the cost of medical liability coverage for providers and facilities,

(3) reduce incentives for defensive medicine that does not improve outcomes, and

(4) align the medical liability system with the clinical standards and safety goals of the

SAFECARE Plan in a way that improves patient safety over time.

(b) Scope. This title applies to any claim for personal injury or wrongful death that

(1) arises from the provision of, or failure to provide, health care services by a provider, and

(2) is paid in whole or in part, directly or indirectly, from the Trust Fund.

(a) Establishment. There is established an independent board to be known as the National Clinical Standards Board (in this Act referred to as the "Board").

(b) Membership. The Board shall consist of 15 members appointed by the Comptroller General of the United States. The Comptroller General shall seek to ensure that membership includes practicing physicians across major specialties, clinical researchers with expertise in evidence synthesis, and patient advocates.

(c) Duties. The Board shall review and endorse evidence-based clinical practice guidelines for purposes of the safe harbor under section 902 and shall periodically update endorsed guidelines as evidence evolves. The Board may endorse guidelines developed by recognized professional societies or independent guideline bodies.

(d) Publication. The Secretary shall publish endorsed guidelines in a publicly accessible format and shall maintain a current index of guidelines endorsed by the Board for purposes of section 902.

STANDARDS.

(a) Presumption of reasonable care. In any action described in section 901, a provider shall be

presumed to have met the applicable standard of care if the provider shows that

(1) the care at issue was delivered in accordance with clinical practice guidelines, coverage

criteria, or quality standards that were issued or endorsed by the National Clinical Standards

Board established under section 901A, and

(2) the provider documented in the medical record the basis for applying those guidelines,

criteria, or standards to the patient at the time of treatment.

(b) Clinical judgment and justified deviation. A provider may depart from a guideline, criteria, or

standard described in subsection (a) when, in the professional judgment of the provider, the

specific clinical circumstances require a different course of action. If the provider documents in

the medical record, at or near the time of care,

(1) the relevant guideline, criteria, or standard, and

(2) the clinical reasons for deviation in the case of that patient,

then the presumption in subsection (a) shall apply in the same way as if the guideline had been

followed.

(c) Rebuttal. The presumption under this section may be rebutted only by clear and convincing

evidence that

(1) the provider materially misapplied a guideline, criteria, or standard, or

(2) the provider engaged in reckless, intentional, or grossly negligent conduct that no reasonable

practitioner would have considered consistent with the protection of the patient.

(d) No immunity for gross negligence. Nothing in this section shall be construed to shield a

provider from liability for conduct that constitutes reckless disregard of patient safety, intentional

harm, fraud, or impairment due to substance abuse.

(e) Patient rights. The existence of guidelines, criteria, or standards under this Act shall not, by

itself, limit a patient's right to file a claim or to recover economic damages for proven harm.

(a) General rule. In any action described in section 901, the total amount of noneconomic

damages that may be awarded to any claimant for all defendants combined shall not exceed

(1) 500,000 dollars for claims that do not involve catastrophic injury or death, and

(2) 1,000,000 dollars for claims that involve catastrophic injury or death,

for claims arising in calendar years 2026 through 2030.

(b) Catastrophic injury. For purposes of this section, catastrophic injury means permanent and

substantial impairment of a major bodily function. This includes but is not limited to permanent

paralysis, severe traumatic brain injury with lasting functional loss, major loss of vision, or major

loss of limb.

(c) Preservation of economic damages. This section does not limit recovery of economic

damages. Economic damages include past and future medical expenses, rehabilitation costs, loss

of earnings, loss of earning capacity, and the reasonable cost of necessary long term care and

support.

(d) Indexing. Beginning in calendar year 2031, the Secretary shall adjust the dollar amounts in

subsection (a) not less than once every three years. The adjustment shall be based on growth in a

health care wage or cost index defined by regulation. The Secretary shall publish the updated

amounts in the Federal Register.

(e) Exceptional cases. In an exceptional case in which the court finds, after written findings of

fact, that

(1) the injury has resulted in extraordinary and lifelong loss of function, or

(2) the conduct of the defendant displayed reckless disregard of patient safety,

the court may increase the applicable cap in subsection (a) by up to fifty percent for that

claimant.

(f) Multiple claimants and wrongful death. In an action with multiple claimants or a wrongful

death claim that arises from a single act or course of treatment, the court shall apportion the

applicable cap among claimants as justice requires. The total noneconomic recovery for all

claimants combined shall not exceed the applicable amount under subsection (a) as adjusted

under subsection (d), except as increased under subsection (e).

(g) Limited preemption for Trust Fund paid claims.

(1) In general. For actions described in section 901 that are paid in whole or in part from the

Trust Fund, State laws that allow higher noneconomic damages than the caps in this section shall

not apply.

(2) State authority preserved. Except as provided in paragraph (1), States may apply additional

patient protections, procedures, or lower caps, and may maintain or adopt health courts or panels,

provided that such State provisions do not impose higher noneconomic damages than permitted

under this section for Trust Fund paid claims.

(a) Encouragement of specialized forums. The Secretary, in consultation with the Attorney

General, may provide grants and technical assistance to States that establish specialized health

courts or expert panels to hear claims described in section 901.

(b) Features. A health court or panel supported under this section shall

(1) use judges or adjudicators with training or experience in health care law or policy,

(2) make use of neutral medical experts to assist in evaluating standard of care and causation,

(3) issue written decisions that summarize the evidence and reasoning, and

(4) collect and share de identified data on adverse events and rulings to support patient safety

efforts.

The Secretary may coordinate with State insurance regulators to review malpractice insurance

rates for reasonableness, taking into account the liability reforms in this title and data on claims,

and may issue reports on trends in premiums and access to coverage in high risk specialties and

regions.

The Secretary shall promote integration of malpractice claims data with patient safety efforts by

(1) supporting confidential reporting systems for near misses and adverse events, and

(2) encouraging the use of claims analysis to identify patterns, system failures, and opportunities

for prevention, without turning every report into a punishment event for individual clinicians

acting in good faith.

Except as expressly provided in this title, nothing in this title shall be construed to

(1) alter State rules on pleading, discovery, or trial procedure, or

(2) limit the authority of State medical boards to license, discipline, or remove providers.

TITLE X. TRANSITION AND INTEGRATION OF EXISTING PROGRAMS.

SUBSIDIES.

(a) Phased integration. Over the transition period defined in section 1005 and subject to section

207, the essential health

coverage components of Medicare, Medicaid, the Children's Health Insurance Program, and

premium subsidies and cost sharing reductions under the Affordable Care Act shall be integrated

into the Plan.

(b) Protection of beneficiaries. During transition, no individual shall lose coverage or see gaps in

treatment solely because of integration activities.

(a) Core coverage. Essential health services for veterans shall be covered under the Plan in the

same way as for other Plan members.

(b) Supplemental veterans benefits. The Department of Veterans Affairs may continue to operate

programs that provide supplemental benefits and specialized services beyond the national

essential benefit floor.

(c) Territorial access. In United States territories where a full service Department of

Veterans Affairs medical facility is not available within 30 minutes of a veteran's

residence, such veteran shall be automatically eligible to receive essential health services

from any participating SAFECARE provider, with costs reimbursed by the Plan.

(a) Preservation. Nothing in this Act shall be construed to reduce or fundamentally alter the

provision of health services through the Indian Health Service or Tribal Health Organizations

under the Indian Self-Determination and Education Assistance Act.

(b) Option and reimbursement. Eligible American Indians and Alaska Natives may choose to

receive care through the Indian Health Service, the Plan, or both. The Plan shall reimburse

Indian Health Service facilities and Tribal Health Organizations for essential health services

furnished to Plan members at 100 percent of the applicable rates established under section 402.

Federal employee health benefits and other Federal health programs shall be aligned with the

Plan according to a schedule set by the Office of Personnel Management and the Secretary. Basic

essential coverage shall be provided through the Plan. Supplemental benefits may remain

separate.

(a) Sunset of duplicative plans. Private health plans that provide duplicative basic coverage

shall be phased out or converted to supplemental plans that comply with section 105. This

prohibition shall apply to an individual beginning on the date that Plan coverage becomes

effective for such individual under the schedule in section 1005.

(b) Continuity of treatment. The Secretary shall adopt rules so that individuals who are in the

middle of treatment at the time of transition can continue that treatment without interruption.

(a) Planning and buildout. The planning period shall begin on the date of enactment. The

Secretary shall complete key regulations, data systems, enrollment mechanisms, and provider

participation onboarding within 24 months after enactment.

(b) Phase 1, initial launch, year three after enactment. On January 1 of the third calendar

year after enactment:

(1) Automatic enrollment. Subject to readiness certification under section 303A, automatic

enrollment shall begin for:

(A) Individuals enrolled in Medicare, Medicaid, or the Children's Health Insurance Program.

(B) Individuals receiving premium subsidies or cost sharing reductions under the Patient

Protection and Affordable Care Act.

(C) Individuals identified as uninsured under Federal and State records, as determined by

the Secretary.

(D) Individuals who are age 55 or older.

(E) Individuals who are under age 18.

(2) Coverage effective. Plan coverage for essential health services shall become effective for

individuals described in paragraph (1).

(3) Contribution alignment. The employer and individual contributions under sections 202

and 203 shall take effect only with respect to wages paid to, and income of, individuals whose

Plan coverage is effective under this subsection.

(c) Phase 2, expansion, year five after enactment. On January 1 of the fifth calendar year

after enactment:

(1) Automatic enrollment. Subject to readiness certification under section 303A, automatic

enrollment shall expand to include:

(A) Individuals who are age 45 or older.

(B) Individuals who are age 18 through 25.

(2) Coverage and contributions. Plan coverage and contributions under sections 202 and

203 shall take effect for such newly enrolled individuals, consistent with subsection (b)(3).

(d) Phase 3, expansion, year six after enactment. On January 1 of the sixth calendar year

after enactment:

(1) Automatic enrollment. Subject to readiness certification under section 303A, automatic

enrollment shall expand to include:

(A) Individuals who are age 35 or older.

(B) Individuals who are age 26 through 34.

(2) Coverage and contributions. Plan coverage and contributions under sections 202 and

203 shall take effect for such newly enrolled individuals.

(e) Phase 4, full enrollment, year seven after enactment. On January 1 of the seventh

calendar year after enactment, automatic enrollment shall apply to all remaining legal

residents not previously enrolled, subject to readiness certification under section 303A. Plan

coverage and contributions shall take effect for all remaining individuals.

(f) Private coverage coordination.

(1) Individuals not yet enrolled under this section may maintain existing coverage

arrangements, including employer sponsored coverage, until their Plan coverage becomes

effective.

(2) As individuals become enrolled under this section, any private coverage that duplicates

essential health services shall be subject to section 105 prohibitions and the transition rules

in section 1004.

(g) Conforming operations. During the period beginning on the date described in subsection

(b) and ending on the date described in subsection (e), the Secretary shall scale integration,

payment policy, and program integrity operations in proportion to actual enrolled membership

and claims volume and shall prioritize continuity of treatment under section 1004(b).

(a) In general. The Secretary shall provide administrative coordination payments to States that elect to cooperate under section 302(c)(1) for reasonable administrative costs of data sharing, secure systems integration, enrollment support, and transition coordination necessary to carry out titles III and X.

(b) Condition on cooperation. As a condition of receiving a payment under this section, a State shall comply with data provision and cooperation requirements established by the Secretary to carry out section 302, including timely provision of data needed for automatic enrollment.

(c) Permissible uses. Amounts under this section may be used only for:

(1) secure information technology and interoperability.

(2) identity and eligibility matching support.

(3) enrollment assistance and outreach directly related to SAFECARE enrollment.

(4) cybersecurity and privacy controls.

(d) Funding. There are authorized to be appropriated from the SAFECARE Trust Fund such sums as may be necessary to carry out this section.

TITLE XI. GENERAL PROVISIONS.

The Secretary and the Secretary of the Treasury shall issue such regulations as are necessary or

appropriate to carry out this Act.

If any provision of this Act, or the application of such provision to any person or circumstance, is

held invalid, the remainder of this Act, and the application of the other provisions to any person

or circumstance, shall not be affected.

(a) General rule. Except as provided in subsection (b), this Act shall take effect on the date of

enactment.

(b) Main implementation date. The main implementation date for Plan operations, for purposes

of employer and individual contributions and coverage obligations, shall be January 1 of the

third calendar year that begins after the date of enactment. Employer and individual

contributions and coverage obligations shall apply on and after such date only with respect to

individuals whose Plan coverage is effective under the phased schedule in section 1005.

(c) Payroll tax replacement. On and after the main implementation date, the replacement of the

Hospital Insurance payroll tax described in section 205 shall apply.

(d) Full implementation date. The full implementation date for universal automatic enrollment

shall be January 1 of the seventh calendar year that begins after the date of enactment, as

provided in section 1005(e).

Section 6103(l) of the Internal Revenue Code of 1986 is amended by adding at the end the following new paragraph:

"(23) Disclosure of Return Information to Carry Out SAFECARE Act. The Secretary may, upon written request from the Secretary of Health and Human Services, disclose to officers and employees of the Department of Health and Human Services such return information as is necessary for the purpose of establishing eligibility for, and administering enrollment in, the SAFECARE Plan."