One federal payer buys an essential floor through four payment methods matched to cost structure rather than to who owns the building: a reference fee schedule, capacity payment for standby capability, capitation with reinsurance, and hospital global budgets. Delivery stays plural and regional — private practices, nonprofit systems, public hospitals, tribal systems, and a standing public arm of federally chartered Regional Health Authorities, aggregated from entities that already run multi-site operations. Every county is assigned to exactly one Authority, so deserts are attached rather than built. Inside the floor there is no prior authorization, no network denial and no balance billing. A regulated supplemental sits above it, separately priced.
Every eligible resident is enrolled in one federal floor. It covers hospital inpatient and outpatient care, emergency care, primary and specialty care, maternity and newborn care, mental health and substance-use treatment, prescriptions on the AHQB formulary, preventive care at no cost sharing, basic dental prevention and emergency extraction, emergency vision exams, hearing screening, and long-term care at qualifying need.
Three things are absent by design: prior authorization, network denial, and balance billing. A service inside a published national indication is paid on the clinician's attestation. States may add to the floor. They may not subtract from it, waive it, or means-test it.
Coverage in the United States is half-solved. Roughly 92% of residents hold insurance, and the remaining problems are not solved by raising that number: a plan can deny, a network can exclude, a bill can arrive after the fact, and in about a third of counties the care the plan is a claim on does not exist.
A floor defined nationally and adjudicated by published rule removes the first three. The fourth is a delivery problem, handled by capacity payment and the public arm rather than by the benefit definition.
AHQB publishes national coverage indications. A clinician attests that the indication is met; the claim is paid. Rejection is possible for fraud, duplication, ineligibility, or a service outside the indication — never for plan-specific medical-necessity judgement, because no plan-specific judgement exists.
Cost sharing is set by AHQB on evidence, and preventive services carry none. "No premiums, no deductibles" is scoped to the floor and should always be said that way; the regulated supplemental above it is separately priced.
The floor's composition widens over time through the AHQB one-way ratchet: an annual review of whether a supplemental benefit migrates into the floor as its unit cost falls or its evidence strengthens. Migration runs one way only.
- Four payment methods
- The floor defines what is bought; the payment methods define how each service line is paid for.
- Supplemental layer
- Everything above the floor is separately priced and purchased with after-tax income.
- Coverage standard
- The cost-effectiveness corridor governs end-stage life-prolonging therapy only, not the floor at large.
A national floor set by one board is a single point of failure — capture it and you capture American medicine.
Indications are published with their evidence, open to petition by patients, clinicians, societies and manufacturers, appealable to an independent tribunal and then to federal court. Concentration is the risk; transparency and standing are the answer. Payment authority, coverage authority, and audit sit in separate bodies.
Honesty about gaps. Distributed Healthcare has more unresolved specification than other Engines because operational complexity is higher; the items below are flagged for v10.2 specification or for outside expert review.
- Dental beyond prevention phases on a published regional capacity ramp — the ramp is defined, the workforce is not yet built.
- Where the floor ends and the supplemental begins for hearing devices and vision hardware, pending ratchet review.