A national floor, one payer, and payment that matches what each service actually is
America has real insurance problems. Coverage gaps persist. Claims are denied. Networks are narrow. Bills arrive that nobody expected. Distributed Healthcare addresses each of these directly.
It also addresses something insurance cannot reach.
Most Americans hold coverage. Coverage is a claim on care. Where the care does not exist, the claim has nothing to attach to. In a large share of American counties there is no obstetric unit. In many there is no ambulance within twenty-five minutes. Raising the insured share by a few points does not change either fact.
The floor
The Accord establishes a national healthcare floor for every eligible resident. Coverage follows the person throughout life. It does not depend on employment, income, age, or state of residence.
The floor includes primary care, hospital treatment, prescription drugs, reproductive care, mental health services, and long-term care protection. The floor also carries dental prevention and emergency extraction, emergency vision examination, and hearing screening. Comprehensive adult dental, vision correction, and hearing aids sit in the supplemental tier at launch, and they are first in the queue to migrate into the floor as their unit costs fall.
Reproductive coverage includes contraception, prenatal care, childbirth, postpartum and miscarriage care, ectopic-pregnancy treatment, and abortion. It does not vary by state.
Fertility coverage includes two egg-retrieval cycles and the medically appropriate embryo transfers arising from them. Single-embryo transfer is the standard, with limited clinical exceptions. That standard comes from Belgium, which expanded funded cycles on the condition of single transfer and found total costs fell, because multiple pregnancy is what drives neonatal intensive care.
Gender-affirming care is evaluated under the same evidence standards as every other field of medicine. There is no categorical exclusion and no exemption from clinical scrutiny.
Payment method follows cost structure
American healthcare pays for nearly everything the same way. Payment follows units delivered. That method works well for a knee replacement. It works badly for a rural ambulance.
An ambulance service in a small county has almost entirely fixed costs. A station. Two vehicles. Crews on call around the clock. What the county is buying is availability.
But Medicare, Medicaid, and commercial insurers pay ambulance services only when a patient is transported. Where call volume is low and drives are long, transport payments do not cover the fixed costs. Health systems do not acquire ambulance services, because the line does not earn. So rural EMS runs on volunteers.
The Maine Rural Health Research Center measures the result. It defines an ambulance desert as a populated area more than twenty-five minutes from an ambulance station, and it finds millions of Americans living in one, disproportionately in the rural West and Plains.[^1]
Money is part of that problem. So is the payment design, which has no line for availability.
One federal payer administers the floor. Care continues to be delivered through independent clinicians, hospitals, nonprofit systems, private practices, and public providers. Payment method is determined by what the service costs to produce.
Routine professional care uses a national fee schedule, with a volume-diluting mechanism drawn from Taiwan's National Health Insurance: services accrue points, and the value per point is settled against a fixed sector budget, so excess volume dilutes every clinician's realization rather than requiring case-by-case permission.
Hospitals in concentrated markets receive global budgets. Maryland ran this design for a decade under an all-payer rate structure, and the federal AHEAD model now extends it to additional states through 2034, with rural and critical access hospitals explicitly eligible.[^2]
Primary and continuing care may use population-based payment, protected by mandatory outlier reinsurance. Shenfeld, Emanuel and Parikh set out the reinsurance design; it exists to stop a capitated payer from profiting by avoiding or under-treating expensive patients.[^3]
Rural emergency, maternity, transport, and other standby services receive capacity funding. Congress created a version of this in 2023 with the Rural Emergency Hospital designation, which pays a monthly facility amount alongside service rates. Pennsylvania's Rural Health Model has run global budgets for rural hospitals since 2019.[^4]
Under this architecture most of American medicine ceases to pay anyone more for doing more.
This is the Accord's Utility State applied to medicine. Electricity markets learned decades ago that reserve generation cannot be bought with a per-kilowatt-hour price. Capacity is a different product and is purchased separately.
Regional Health Authorities
Regional Health Authorities organize delivery. Their boundaries follow patient travel and referral patterns, including areas that cross state lines. They plan local capacity, support public clinics, coordinate emergency transport, and arrange access to regional specialty centers.
Public delivery remains a permanent part of the system, particularly where private supply is limited.
The model is American and already operating. Federally qualified health centers are community-governed, serve a general population including women and children, and have been funded on a bipartisan basis since the 1960s. NYC Health and Hospitals, Denver Health, Cook County, and Parkland show that public delivery works best when it is local.
The structure is also international practice. The NHS operates through trusts, Canada through regional health authorities, Sweden through regions. No comparable country runs clinical delivery from its capital.
Regional referral follows the design American medicine already built for newborns. Perinatal care is organized by level of nursery, with defined capability at each level, defined referral relationships, and organized maternal and neonatal transport. Distributed Healthcare extends that structure to trauma, cardiac, stroke, and sepsis care, and conditions a receiving center's budget on accepting transfers from its assigned catchment. State lines do not determine whether a newborn is accepted.
The Authorities are not a competition strategy. In a one-hospital market there is nothing to compete with, and prices are controlled by the payer instead. What the public arm does is hold the floor open where nothing else will. It gives the rate-setter a published cost anchor, because a public system operating at audited cost establishes what a service costs to deliver. And it removes the incentive to over-treat, since a salaried physician who orders an unnecessary scan gains nothing by it.
Veterans
The Veterans Health Administration continues as an independent veteran-priority system. It retains its clinical mission and restores direct capacity where community purchasing has weakened continuity.
The VHA and Regional Health Authorities may share facilities, training programs, laboratories, transport, and other infrastructure when this improves care. Veteran governance and priority remain intact.
The coverage board
The American Healthcare Quality Board determines which treatments the floor covers and the clinical situations in which coverage applies. A covered treatment is paid when the published indication is met. There is no prior authorization, no plan-specific denial, no network denial, and no balance billing for floor care.
Congress establishes the evidence rules, the cost-effectiveness corridor, and the disability protections. AHQB applies those rules and publishes its reasoning.
Rarity permits evidentiary flexibility, because a condition affecting four hundred people cannot generate the trial a common one can: smaller studies, validated surrogate endpoints, registries, outcomes-based payment. It does not change what a health year is worth. There is no rarity modifier.
The institutional model is the National Institute for Health and Care Excellence in the United Kingdom, which has published its methods and its reasoning for a quarter-century and absorbs the public argument that individual decisions generate. Severity weighting uses proportional shortfall, a method developed in the Netherlands and adopted by NICE, which measures how much of a normal lifetime health expectation a condition removes and therefore does not penalize patients who begin from a lower baseline.
The corridor applies narrowly. It governs end-stage interventions whose purpose is delaying death. It does not govern the rest of medicine. A hip replacement, a cataract operation, insulin, and a hearing aid are clinical determinations made on evidence of benefit, in the ordinary way.
Where an intervention extends life, only the health state attributable to the condition being treated is measured. Everything else is set at the general-population norm for that age, so a wheelchair user with a terminal illness is scored on the illness and not on the wheelchair. Earning capacity, caregiving burden, and social contribution are excluded from every determination.
Any life-extending intervention in advanced disease carries concurrent access to palliative care. Temel and colleagues found that early integrated palliative care in metastatic lung cancer improved quality of life and mood, produced less aggressive care at the end of life, and extended survival.[^5]
Patients and clinicians have access to reconsideration and to exceptional-case review. Where treatment is urgent, it proceeds under provisional payment while review is conducted, and the patient is never billed because a reasonable clinical exception was unsuccessful.
Utilization review is retrospective and statistical. Practice above the ninety-fifth percentile, adjusted for patient risk, triggers professional examination rather than a finding of wrongdoing. The sequence is explanation, then peer review, then education, then a corrective plan.
The workforce
Coverage without clinicians is a promise on paper. The binding constraint in this program is people, not money, and the evidence about how to recruit them is clear and counterintuitive.
Admissions matters more than tuition. What predicts rural practice is rural origin, rural training, and stated intent at matriculation. The lifetime income difference between rural family medicine and a procedural specialty is far larger than any debt a scholarship can retire.
So the Accord funds a rural-origin track built on the Australian rural generalist model: family medicine with advanced procedural skills in obstetrics, anaesthetics, or emergency medicine, so that a small town has someone who can perform a caesarean section. Japan reserves medical school places for students from underserved prefectures under its regional quota system, with a service obligation attached. Both countries built these programs for a geography problem comparable to America's.
The Accord also expands the historically Black medical schools, because the supply loss there has a documented cause. The 1910 Flexner Report recommended that among historically Black medical schools only Howard and Meharry remain, and five others closed. Campbell and colleagues estimated what those five schools would have produced had they stayed open, and the figure runs to tens of thousands of physicians never trained.[^6]
The case is present as well as historical. Alsan, Garrick and Graziani randomized Black men in Oakland to Black or non-Black physicians and found substantially higher acceptance of preventive services, particularly invasive ones, under racial concordance.[^7]
The payment schedule is itself a workforce instrument. The reference schedule steps down asymmetrically. Primary care, psychiatry, and obstetrics are held or raised. Reductions fall on procedural specialty differentials. Compressing that spread redirects entering medical students more powerfully than any scholarship program in American history.
Nursing carries its own rule, and it follows directly from the payment architecture. Under a global budget, revenue is fixed and nursing labor is the largest controllable cost. Enforceable minimum staffing standards are therefore a condition of global budget participation and of capacity payment eligibility. Aiken and colleagues established the association between nurse staffing levels and patient mortality, and California has operated mandated minimum ratios since 2004.[^8]
The supply constraint on nursing is the largest in the program and the cheapest to fix. Nursing schools turned away more than ninety thousand qualified applications last year, which is roughly forty thousand people once you account for one applicant applying to several schools. None of that is a shortage of people who want to nurse. It is a shortage of teaching: faculty, clinical placements, preceptors, and simulation capacity. A doctorally prepared nurse educator earns less than the same person earns in clinical practice, which is why the faculty line does not fill.
Clearing all four constraints costs a few billion dollars a year against a program measured in trillions. It belongs in the first year rather than the fifth because of the lag: four years from a funding decision to a nurse at a bedside.
Long-term care
Medicaid currently requires older Americans to exhaust a lifetime of savings before it will pay for long-term care. That is wealth destruction used as an eligibility test.
Distributed Healthcare removes the asset test and keeps an income-related contribution above a basic tier. Germany has run long-term care as social insurance with assessed benefit levels since 1995, and Japan since 2000. Neither is free at the point of use, and neither requires impoverishment to qualify. Germany also pays family caregivers a cash benefit set below the equivalent facility rate, which compensates real care without making paid substitution attractive.
The launch benefit is deliberately frugal: catastrophic protection, assessed home and community-based services, and respite.
For dementia, the clinical work sits inside the Regional Health Authorities. Medicare's GUIDE model, launched in 2024, already does approximately this. Residential capacity sits outside them, on the small-house model pioneered by Green House, which houses ten to twelve residents and has outperformed institutional facilities on outcomes. The Program of All-Inclusive Care for the Elderly is the integration precedent, and it has kept nursing-home-eligible people in their communities for decades.
Why this is an Accord program
The Accord manages four asset classes for return. Human, built, natural, institutional. Health belongs to the largest of them, and the reason American healthcare resists being run as an investment is structural.
Fragmented insurance pushes health investment onto someone else. Commercial insurers lose a substantial share of their members every year. An intervention that pays off in a decade is, to the entity funding it, a gift to a competitor. Every American insurer therefore faces a rational incentive to underinvest in exactly the long-horizon prevention the Accord treats as central.
A permanent payer with lifetime enrollment keeps what it invests. This is the argument the Accord already makes about carbon, applied to human capital instead of the atmosphere.
Some obligations are commitments rather than investments, and the Accord says so. An ROI framework keeps its credibility only by refusing to run commitments through it. Rural emergency access belongs in the category of universal service obligation, which America has accepted for a century in rural electrification, in postal delivery, and in telephone service. Some rural facilities cannot clear a return threshold at any defensible discount rate. The Accord funds them anyway.
This follows the Accord's standing rule that grid hardening and defense infrastructure are general-fund obligations already owed. Rural emergency capability belongs to the same category.
Benefits expand when delivery is proven, not when cash allows. The program expands according to available workers and facilities. Spending reports include both cash expenditure and unmet care, because spending that falls while care goes undelivered is not a saving. Additional benefits are considered only after the existing floor is being delivered reliably.
A country that earns its best future does not buy a new promise while an old one is still undelivered.
Cost
The transition years cost more than the status quo. Much better care at much lower and controllable cost as the program matures.
Say the first part plainly, because every honest version of this reform has it and most proposals bury it. Coverage expands, untreated need enters the system, and the legacy programs keep running at full cost until each population actually moves. Total health spending rises from about 18 percent of GDP to a peak near 19.5 percent in the third year, at maximum overlap, and crosses below the current-law path in the fourth or fifth. That cost is planned, and it buys the platform, the workforce, and the delivery capacity that everything afterward depends on.
A program showing savings in year one would be booking a fold before the population moved.
The later savings come from price discipline. Administrative savings are real and are the smaller lever. American clinical and hospital prices run far above those in comparable countries, and closing that gap is the substance of the reform. Average clinician compensation falls under any version of this that works, which is why the schedule compresses the spread rather than cutting uniformly, and why clinicians receive liability reform, the end of prior authorization, and relief from administrative burden in exchange.
Cost becomes controllable because the mechanisms are automatic rather than discretionary. The point-value settlement adjusts continuously. The fee schedule is revised on a fixed cycle, a practice Japan has used for decades. A published brake governs the outer limit and reads access-adjusted spending rather than cash alone.
The floor-plus-supplemental structure was derived independently by Finkelstein and Einav, who reached a comparable architecture from a different starting point: a universal, automatic, deliberately basic floor, with the option to purchase above it.
What this does not claim
The public arm will not discipline monopolist hospital prices through competition.
Capacity payment alone does not produce access. Rural Emergency Hospital conversions have clustered near other hospitals, and at least one early converter closed anyway once patients began driving past a facility that had lost inpatient capability.
Defensive-medicine savings from liability reform are modest. Liability reform is worth doing because it purchases the price reduction, rather than because it pays for itself.
Full obstetric access arrives late. The rural generalist pipeline runs the better part of a decade, and promising faster would be promising something the pipeline cannot deliver.
If price discipline fails politically, the program costs more than current law rather than less. That is the principal failure mode, and it is a reversal rather than a reduced margin.
A dozen separate legislative fights are required, and they are named rather than assumed.
Every component of this program exists somewhere already, and the sources are named above. What the Accord adds is the assembly, the delivery-side count, and the published cost of being wrong.
References
[^1]: Maine Rural Health Research Center, Ambulance Deserts: Geographic Disparities in the Provision of Ambulance Services. https://digitalcommons.usm.maine.edu/ambulance_deserts/
[^2]: CMS AHEAD Model (States Advancing All-Payer Health Equity Approaches and Development), 2024–2034, successor to the Maryland Total Cost of Care Model. https://www.cms.gov/priorities/innovation/innovation-models/ahead
[^3]: Shenfeld E, Emanuel EJ, Parikh RB. "A Reinsurance Program to Mitigate Selection in Medicare Advantage." Health Affairs, 2025.
[^4]: Rural Emergency Hospital designation, Consolidated Appropriations Act 2021, effective January 2023. Conversion tracking and financial analysis: University of North Carolina Sheps Center for Health Services Research. https://www.shepscenter.unc.edu/programs-projects/rural-health/ · Pennsylvania Rural Health Model, 2019.
[^5]: Temel JS, Greer JA, Muzikansky A, et al. "Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer." New England Journal of Medicine 2010;363(8):733–742. https://www.nejm.org/doi/full/10.1056/NEJMoa1000678
[^6]: Campbell KM, Corral I, Infante Linares JL, Tumin D. "Projected Estimates of African American Medical Graduates of Closed Historically Black Medical Schools." JAMA Network Open 2020;3(8):e2015220. https://pmc.ncbi.nlm.nih.gov/articles/PMC7441360/
[^7]: Alsan M, Garrick O, Graziani G. "Does Diversity Matter for Health? Experimental Evidence from Oakland." American Economic Review 2019;109(12):4071–4111. https://www.aeaweb.org/articles?id=10.1257/aer.20181446
[^8]: Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. "Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction." JAMA 2002;288(16):1987–1993. · California AB 394 (1999), minimum nurse-to-patient ratios implemented 2004.
Further sources
Payment and delivery. Taiwan National Health Insurance global budget with floating point value. · Japan biennial fee schedule revision. · Federally Qualified Health Center program, Public Health Service Act §330. · American Academy of Pediatrics levels of neonatal care. · Certified Community Behavioral Health Clinic model.
Long-term care. Germany, Pflegeversicherung (1995) and Pflegegeld. · Japan, Kaigo Hoken (2000). · CMS GUIDE Model (2024). · Green House Project. · Program of All-Inclusive Care for the Elderly.
Coverage determination. National Institute for Health and Care Excellence, published methods guides. · Proportional shortfall severity weighting, Netherlands.
Workforce. Australian College of Rural and Remote Medicine, rural generalist curriculum. · Japan, chiiki-waku regional quota system. · Jefferson Physician Shortage Area Program. · University of Washington WWAMI program.
Fertility. Belgian single-embryo-transfer funding reform. · CDC Assisted Reproductive Technology National Summary, https://www.cdc.gov/art/php/national-summary/index.html
Convergent architecture. Finkelstein A, Einav L, We've Got You Covered: Rebooting American Health Care (2023). · Center for American Progress, Medicare Extra for All (2018). · Berwick DM, Johnson KA, "Medicare 2.0."
The build model, price model, durability model, and uncertainty analysis are published with the technical white paper, along with the parameters most worth challenging.