Probabilistic Forecast · 2026 Baseline
Will Your Group Health Plan Exist in 2046?
Every renewal season someone asks whether any of this matters in ten years, or whether the government just takes it over. The answers are always vibes. Vibes are not a planning input. So here are the odds, from 8,000 simulated futures.
Free. No login. Every assumption is a slider, and you are welcome to disagree with all of them.
Why Build This At All
Because the ten-year question gets asked in every boardroom and answered with a shrug.
Six Futures, Argued Like One
"Universal healthcare" gets debated as a single event. It is six different futures, and they have wildly different odds. Single payer sits at 7% over 20 years. The individual market becoming the default sits at 90%.
The Number Nobody Tracks
Reform odds get modeled off elections. History says elections are half the story. The other half is how far premium growth has pulled ahead of wages, added up year over year.
Two Clocks, One Window
The Medicare hospital trust fund empties in 2033. At current trend, households cross the historical breaking point in the mid-2030s. Two pressure points, the same five years.
Attack the Sliders
Every assumption here is exposed and adjustable. Think the AI input is overweighted? Drag it to zero and watch what survives. That's the difference between a forecast and an opinion.
First, Define the Thing
Six futures get argued about like they are one. The model forecasts each on its own. Percentages are 20-year cumulative odds at the 2026 baseline, and scenarios can overlap.
The Engine Underneath: The Middle Class Squeeze
Every modern reform attempt happened when the built-up premium-wage gap crossed roughly 40 points while one party held the government. When the gap was not there, holding the government produced nothing.
The gap reset to zero in the calm 2010s. It started building again around 2024. Milliman put 2026 cost trend at 7.9% against wage growth in the mid-3s. At that pace the US crosses the 40-point line again in the mid-2030s, which is the same window the Medicare hospital trust fund empties. Two pressure points, one five-year window. That is the core finding.
Run It Yourself
8,000 runs across the 2028 to 2044 election cycles. Start with a preset, then move any slider and watch the odds move with it. The sensitivity panel ranks which assumption is doing the most work.
The 2026 edition as published. Every number in the article comes from this run.
Scenario ladder · cumulative probability by horizon
- S1 · Patchwork universality3 yr: 8.6%5 yr: 14.2%10 yr: 32.1%20 yr: 62.1%
97%+ covered via subsidies, auto-enroll, and Medicaid. No structural change.
- S2 · Public option ◆3 yr: 0.0%5 yr: 9.0%10 yr: 20.3%20 yr: 49.4%
A federal government plan competing on the exchanges.
- S3 · Medicare expansion ◆3 yr: 0.0%5 yr: 9.3%10 yr: 21.6%20 yr: 52.6%
Eligibility age drops to 60 or 55, or a buy-in opens.
- S4 · ICHRA-led individual migration3 yr: 5.4%5 yr: 11.8%10 yr: 35.2%20 yr: 89.6%
The individual market becomes the default. Group plans recede.
- S5 · All-payer rate setting3 yr: 0.0%5 yr: 2.5%10 yr: 6.2%20 yr: 14.3%
The Maryland model goes national. Plans persist, pricing is regulated.
- S6 · Single payer (M4A) ◆3 yr: 0.0%5 yr: 0.8%10 yr: 1.9%20 yr: 6.6%
Employer coverage is eliminated as the primary source of insurance.
Bars show 20-year cumulative probability. Terracotta = market drift. Sand = an act of Congress. ◆ = squeeze-sensitive. Correlations are active: S2 or S3 passing suppresses S6, S4 maturity suppresses all legislative demand, and S1 suppresses mildly.
Priors · adjust and stress-test
Political
Squeeze
AI Labor
Shocks
Drift
Sensitivity · change in 20-yr structural odds per +25% prior bump
Running the sensitivity sweep…
The longest bar is the assumption doing the most work. If you want to argue with this model, argue with that one first.
8,000 runs per update, 2026 baseline. Seeded, so the same priors always return the same odds.
The Finding That Matters for Your Plan
Flip through every preset. Baseline, bear, bull, AI disruption. One result holds every time.
The market beats Congress. Scenario 4, where individual coverage becomes the default, has better 10-year odds than any single act of Congress, and its 20-year odds dwarf every legislative path. It needs no trifecta, no filibuster fight, no signing ceremony. It builds through thousands of individual renewal decisions. Every force that raises reform pressure speeds it up too.
Here is the cruelest twist in the model. Every person the individual market picks up is one less voter demanding a new law. The market is not just beating Congress to the fix. It is taking away Congress’s reason to act.
What a CFO Does With a Probability Table
You do not plan for one scenario. You plan for the spread. Three moves hold up across every horizon.
Calibration and Sources
Baseline frozen August 2026. Every dated input, what it came from, and when it was last checked. The model refreshes each year against the new Trustees Report, the KFF employer survey, cost trend data, and election results.
- Employer health cost trend, 20267.9%Per-person cost $7,838 to $8,460. Highest annual increase in over a decade outside the pandemic years. Family of four at $37,824.
- Medicare HI trust fund depletionQ2 2033One quarter earlier than the 2025 report projected. At depletion, income covers about 89% of Part A expenses.
- Premium vs wage divergence, 1999-2010premiums +138%, wages +42%The ~55-point cumulative gap entering 2009 that calibrates the 40-point breaking threshold.
- Premium vs wage divergence, 2020-2025 (negative control)premiums +26%, wages +28.6%Family premium reached $26,993 in 2025, up from $21,342 in 2020. No divergence, and the 2021 trifecta produced no serious reform attempt.
- ICHRA covered lives500,000+ (HRA Council); ~1M on a broader countHRA Council puts ICHRA-covered lives above 500,000 entering 2026. The ~1M figure is a broader third-party count (SureCo) covering all ICHRA benefit recipients. Attribute whichever one you quote.
- ICHRA employer adoption growth20,000+ employers, +53% YoY; large-employer adoption more than doubledApplicable large employers (50+ FTE) are the fastest-growing segment, more than doubling year over year. That is well above the +34% the 2026 baseline was calibrated on, so the S4 drift prior is conservative rather than aggressive.
- Outside-view anchor for federal universal healthcare~30% by 2040The question exists under this title and id, but the live community number could not be read from this environment. Re-check the current percentage before publishing, since the article quotes it directly.
Method: 8,000-run Monte Carlo across the 2028 to 2044 election cycles. Political inputs at baseline: 28% chance of a trifecta per cycle, 30% chance of filibuster reform given one. Squeeze engine: 7.5% premium growth against 3.5% wage growth, with a 40-point breaking threshold tested against 1993 and 2009 and 2021 as the negative control. Scenario correlations are active, so partial reforms and market migration reduce demand for bigger reforms.
The Questions Everyone Asks
Short answers, for the person who signs the renewal.
What are the odds the US adopts universal healthcare?
It depends entirely on what you count. This model runs six definitions separately. Any universal path, including a market-led one, reaches 99% over 20 years. Any structural act of Congress reaches 70%. Single payer, where employer coverage is eliminated, sits at 7%. The three-year odds of structural change are zero, because no Congress capable of passing a big healthcare law gets seated before 2029.
Will employer-sponsored health insurance go away?
Not by legislation, on these numbers. The likeliest path away from group coverage is market drift, not a law. Scenario 4, where ICHRA-style individual coverage becomes the default, carries 35% odds at 10 years and 90% at 20. It needs no trifecta and no signing ceremony. It builds through thousands of individual renewal decisions.
Why does this model run hotter than other forecasts?
The Metaculus community puts federal universal healthcare legislation at roughly 30% by 2040, and this model is near 50% by 2040. Two reasons, and you can attack either. First, definition: the structural bucket here counts a public option, a Medicare buy-in, or national rate setting, which change the market without being universal healthcare as Metaculus would score it. Second, mechanism: this model counts the premium-versus-wage gap and AI-driven coverage loss, which most gut estimates do not price at all.
What happens when the Medicare trust fund runs out in 2033?
The 2026 Trustees Report projects the Hospital Insurance trust fund is depleted in the second quarter of 2033, a quarter earlier than the year before. Incoming revenue then covers about 89% of Part A expenses, which forces an automatic payment cut absent congressional action. In this model that event acts as a fiscal catalyst: it raises the odds something gets attempted, without raising the odds it passes.
How reliable is the AI job-loss input?
It is the least proven input in the model, and it is labeled that way on purpose. Nothing in history looks like AI-scale white-collar displacement. 2009 is the closest analog and that was a recession, not machines replacing workers. So the model publishes a range instead of pretending to precision. Set the slider to zero if you disagree, and see which conclusions survive. Most of the S4 result does.
What should a CFO actually do with this?
Plan for the spread, not for one scenario. Build the ability to change how you fund benefits without organizational trauma, get fluent in your workforce’s individual market whether or not you ever use it, and watch the premium-wage gap and the share of workers with group coverage. The Funding Fit assessment scores the first of those three in about 60 seconds.
Keep Going
The forecast frames the decision. These tools do the math on what you control.
Want the CFO Version of This Conversation?
30 minutes. We'll take the scenario you built and pressure-test it against your actual plan, your actual renewal, and what flexibility would really cost you to build.