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Table 1: Baseline U.S. Healthcare Spending (2024)

This table is built around the Centers for Medicare & Medicaid Services’ own “type of sponsor” breakdown of the $5.3 trillion National Health Expenditure — the classification CMS uses to divide healthcare spending by who ultimately pays, which is the only version of this table that reconciles to the total by construction.

Source: CMS, “National Health Expenditures 2024 Highlights.”

Illustrative federal-program detail (partial, not additive to the sponsor table above)

The rows below break out the largest named federal programs folded into the “Combined Public Spending” figure above. They are illustrative, not a second independent total — they do not sum to $2.5 trillion on their own, because Combined Public Spending also includes non-Medicare/Medicaid federal outlays and the roughly $860 billion in state and local government spending (state Medicaid share, public employee health benefits, state hospital and public-health spending) that the program-by-program list below does not itemize line by line. Figures below carry the vintage noted for each program; where 2024 figures were not yet finalized at time of writing, the most recent confirmed CMS/KFF figure is used and labeled.

Source: Centers for Medicare & Medicaid Services (CMS), National Health Expenditure Accounts and “National Health Expenditures 2024 Highlights”; Kaiser Family Foundation (KFF), “Medicare 101” and Medicaid enrollment trackers; Congressional Budget Office (CBO). Medicare enrollment reflects CMS NHE (66.6M) and KFF’s broader Medicare-101 count (68M); Medicaid/CHIP enrollment reflects the 2024 decline from 92.2M (2023) driven by post-pandemic eligibility redeterminations.

Source: Centers for Medicare & Medicaid Services (CMS) National Health Expenditure Accounts; Kaiser Family Foundation (KFF); Congressional Budget Office (CBO).

Table 2: The Three-Column Fiscal Framework

Every dollar in the Total Choice Health proposal is classified as exactly one of the following. No dollar appears in more than one column.

Column A — Real Savings (genuine resource reduction)

Column B — Transfers (not savings; dollars already in the system, relocated)

Column C — Revenue (genuine new Treasury receipts)

Note: The ESI tax exclusion’s full 10-year cost is estimated at $3.9 trillion (income tax only) or $5.9 trillion (combined income and payroll tax) by Treasury/OTA analyses. It is also widely documented as regressive — its value rises with the taxpayer’s marginal tax rate, meaning it disproportionately benefits higher earners with more generous employer plans.

Column D — New Costs (owned explicitly, not hidden inside “savings”)

Table 3: International Comparators

Source: OECD Health Statistics; Swiss Federal Office of Public Health; Dutch Ministry of Health, Welfare and Sport.

Design Safeguards Required in Implementing Legislation

1. Risk adjustment, not a flat voucher — benchmark premiums must be adjusted for age and health status to prevent adverse-selection competition among insurers.
2. Statutory indexing rule — the voucher must be indexed to medical inflation (not general CPI) in the authorizing statute itself, to prevent the benefit from silently shrinking over time.
3. Standardized benefit product — plans compete on price, network, and service, not on obscuring benefit design.
4. Non-transferable card with capped carryover — prevents the voucher from becoming a disguised cash-out program.
5. Cohort-based transition — phased implementation by population segment (uninsured and individual market first; then Medicaid, ACA, TRICARE, and routine VA care; then the employer-sponsored population and new Medicare-eligible retirees) to manage fiscal and administrative load, with no current Medicare enrollee ever forced to move.
6. Human review requirement — no coverage or claims determination may rest solely on an automated system without meaningful human review and a real appeal right.
7. Specialized VA hospital capacity carved out — polytrauma, PTSD, spinal-cord-injury, and other trauma-specific VA programs remain outside the voucher marketplace; only routine primary and preventive veteran care converts.
8. Independent risk-adjustment fraud audits — because a voucher model shifts fraud risk from fee-for-service billing to risk-score upcoding, implementing legislation must fund randomized clinical-record audits of insurer risk-adjustment scores, mandate overpayment clawbacks with real penalties, and publish insurer-level upcoding rates.

Sources

Centers for Medicare & Medicaid Services (CMS), National Health Expenditure Accounts, 2024; Kaiser Family Foundation (KFF), Employer Health Benefits Survey and health spending trackers; Congressional Budget Office (CBO), federal subsidy and tax expenditure projections; Joint Committee on Taxation (JCT), Estimates of Federal Tax Expenditures; U.S. Department of the Treasury, Office of Tax Analysis; American Hospital Association, uncompensated care cost estimates; OECD Health Statistics; Swiss Federal Office of Public Health; Dutch Ministry of Health, Welfare and Sport.