was phased in, the administrative savings from switching to a single-payer system would offset much of the increased demand for health care services. Later, the cap on the growth of the national health budget would hold the rate of growth of spending below the baseline." The CBO also scored Sen. Paul Wellstone's American Health and Security Act of 1993 in December 1993, finding that "by year five (and in subsequent years) the new system would cost less than baseline." A 2014 study published in the journal BMC Medical Services Research by James Kahn, et al., found that the actual administrative burden of health care in the United States was 27% of all national health expenditures. The study examined both direct costs charged by insurers for profit, administration and marketing but also the indirect burden placed on health care providers like hospitals, nursing homes and doctors for costs they incurred in working with private health insurers including contract negotiations, financial and clinical record-keeping (variable and idiosyncratic for each payer). Kahn, et al. estimate that the added cost for the private insurer health system in the US was about $471 billion in 2012 compared to a single-payer system like Canada's. This represents just over 20% of the total national healthcare expenditure in 2012. Kahn asserts that this excess administrative cost will increase under the Affordable Care Act with its reliance on the provision of health coverage through a multi-payer system. A February 2020 study published in The Lancet found that the proposed Medicare for All Act would save 68,000 lives and $450 billion in national healthcare expenditure annually. According to a 2022 study published in the Proceedings of the National Academy of Sciences of the United States of America, a single payer universal healthcare system would have saved 212,000 lives and averted over $100 billion in medical costs during the COVID-19 pandemic in the United States in 2020 alone. Roughly 16% of all COVID-19 deaths occurred in the US, despite having only 4% of the world's population. State proposals Several single-payer state referendums and bills from state legislatures have been proposed, but with the exception of Vermont, all have failed. In December 2014, Vermont canceled its plan for single-payer health care. California California attempted passage of a single-payer health system by initiative in 1994, as Proposition 186, which got 27% of the vote. Multiple legislative proposals have been proposed in the state