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.
Social Security and the Dignity Floor handle income in old age. The long-term-care obligation is different: insurance against care costs that exceed what any income floor could absorb. Nursing facility care runs well past $100,000 a year, which is why Medicaid became the default payer through spend-down.
Stated as universal long-term care, the obligation invites an open-ended reading. Stated as ending eligibility spend-down, it does not.
Spend-down requires impoverishment as the price of care. It is the single most punitive feature of American long-term care and it falls hardest on people who saved.
Long-term care is also the only spending category that rises under this architecture — about 31% at Year 15. That is the intended effect of ending spend-down, and it should be presented openly rather than netted into a total.
A basic assessed benefit covering home and community-based care at qualifying need, with no asset test. The gate is substantial impairment in two or more activities of daily living, or substantial cognitive impairment with safety risk, assessed by certified assessors with scheduled reassessment.
Above the basic tier, income- and asset-related contribution. Japan charges 10–30% scaled to income; Germany's Pflegeversicherung covers part of facility cost with the resident paying the balance. Neither is free at point of use. Estate recovery follows, which is spend-down deferred to the moment the Accord's realization architecture already taxes — and the reason the asset test can go while the contribution survives.
The launch benefit is deliberately frugal: catastrophic protection, assessed basic home and community-based services, and respite. Expansion is statutory and gated on multi-year fiscal, access, workforce and construction tests. A cash surplus alone is insufficient.
Memory care splits. Inside the Authority: diagnosis, staging, care planning, medication oversight, behavioural crisis response, caregiver training. Outside: the residential layer, separately chartered and capitalized, with the Authority holding oversight and standing acceptance obligations.
Every actuarial attempt at a universal long-term-care benefit has underestimated it.
Which is why the launch is frugal, the envelope is separately scored with its own brake, and expansion is gated rather than scheduled. Dementia is the specific strain: advanced disease needs 24-hour supervision at facility cost, which a basic home-care tier does not reach.
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.
- The cash-in-lieu ratio is the load-bearing undetermined parameter — roughly $500B of unpaid family caregiving sits adjacent, and the ratio decides how much converts to paid.
- Residential memory-care supply does not exist at the scale projected demand implies.