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Single-payer universal health care has long been perceived as politically and economically impractical in the USA. However, the national health insurance programme Medicare is a 54-year-old, real-world test for the viability of single-payer, government-funded health care. In 1965 Medicare was established in response to the widespread refusal of private sector companies to provide insurance for older patients (≥65 years), it has significantly and cost-effectively improved the health of older people. 14, 15, 16 Public opinion is clear: the vast majority of Americans view Medicare as an important programme that works well. 17 If Medicare can succeed in the age cohort that uses health-care services most frequently, it is reasonable to expect that extending coverage to all Americans would only be more feasible and less costly per capita. Previous estimates of the national cost of health care under the Medicare for All Act range from a 16·9% increase to a 27% decrease. 18, 19, 20, 21, 22, 23, 24 In this study, we estimate the national health-care expenditure under the single-payer universal health-care system detailed in the Medicare for All Act. Furthermore, we consider the robustness of our budgetary projections by systematically altering the values of key parameters that underlie health-care system costs in our model. As highlighted by the divergent conclusions of the previous Medicare for All Act evaluations, 18, 19, 20, 21, 22, 23 these inputs can vary as a result of differing expert opinions or empirical uncertainties. Accordingly, we develop the Single-payer Healthcare Interactive Financing Tool (SHIFT) in which these parameters can be adjusted (figure 1). SHIFT similarly enables the customisation of a national financing plan in which insurance premiums paid by employers and individuals would be replaced with other options, such as a payroll tax. Projections from SHIFT indicate that the Medicare for All Act would yield net savings for the health-care system across a wide range of assumptions regarding insurance expansion, service improvements, administrative efficiency, and pharmaceutical pricing (figure 2; panel). [Charts omitted] Parameter defaults and bounds for the Single-payer Healthcare Interactive Financing Tool (SHIFT) The following parameters are adjustable within our user-friendly tool, SHIFT. We provide a rationale for the default values, which correspond to our base case (default) analysis and the lower (minimum parameter value) and upper (maximum parameter value) bounds. Further details on input parameters and assumptions are provided in the appendix pp 1–13. Health-care budget Reducing reimbursement rates for hospitals If all hospital fees were reimbursed at 2017 Medicare amounts, the fees would overall be 5·54% lower (default); however, if reimbursed at Medicaid rates, fees would be reduced by 18·74% (upper bound). Reducing reimbursement rates for physician and clinical services If all physician and clinical services were reimbursed at current Medicare rates, the fees would be 7·38% lower (default), and if reimbursed at Medicaid rates, fees would be reduced by 19·23% (upper bound). Reducing pharmaceutical prices via negotiation The Department of Veterans Affairs has the authority to negotiate prices in accordance with therapeutic value, achieving prices that are 40% lower than those paid by the Medicare scheme (default). 25 Reducing overhead expenditure Within the US health-care system, insurance overheads range from 2·2% for Medicare (lower bound; default) to 12·4% for the private sector (upper bound). 26 Improving fraud detection Given estimates that 4% of health-care expenditure (default) could be eliminated through fraud detection within the first two years of implementing a single-payer system, 27 we allow fraud reduction to range from 0% (lower bound) to 10% (upper bound) upon enactment of the Medicare for All Act. Expansion in service use Health-care service use by people who are uninsured and underinsured is expected to range from current levels (lower bound) to usage commensurate with those who are fully insured (default, upper bound). Revenue generation Payroll tax The $536 billion spent by employers on health-care premiums is equivalent to a 12·29% payroll tax (upper bound). Any payroll tax that collects revenue below the 12·29%-level expenditure would represent savings, including our default value of 10%. Household income tax Households currently pay $738 billion towards premiums and out-of-pocket expenditures. Only $64 billion of out-of-pocket costs would remain under the Medicare for All Act. If the remaining $674 billion in spending were replaced by a 5% household income tax (default) on income beyond the standard deduction, the tax would yield $375 billion annually. 28 The $674 billion replaced by Medicare for All Act would be equivalent to a tax rate of 9% (upper bound). The Sanders net worth tax A 1% tax on household net worth above $21 million, applied to 0·1% of all households in the USA, would yield $109 billion annually. 28 This tax rate can be modified to range from 0% (lower bound, default) to 2% (upper bound).