Coverage is universal from day one and never partial. What improves over time is the distribution of travel times — a mean, a spread and a tail — moved down by density and staffing. A distribution has no completion state, so access is never reported as a percentage complete. It is measured by condition and time to definitive care, and its honest milestone is the crossover year when as many sites open as close: net-negative today, and plausibly a twenty-year horizon. This clock runs separately from the transition, and for longer.
Physical and institutional construction totals roughly $94B across ten years, with about $56B annually in new operating cost. Against a system running trillions, the build is a rounding error: 0.78% of national health expenditure, and peak-year capital is about a quarter of the healthcare construction the United States already puts in place each year.
New-site and pre-hospital workforce totals 85,821 clinical full-time equivalents, of which the rural-generalist pipeline is the slowest line. That figure counts prescribers and pre-hospital crew and does not include the staff nursing workforce, which is larger and is modelled separately.
Nearly every American healthcare proposal is a financing proposal. This one quantifies the delivery side in units, workforce and ramp, because coverage without capacity is a claim on care that does not exist.
Regional control is what keeps the number small. Authorities convert existing hospitals, clinics, pharmacies and unused facilities before constructing new ones. A civilian expansion of the VHA would instead have meant building pediatrics and obstetrics from zero inside an institution that has essentially neither.
The public arm builds roughly 22% of the measured gap in large metros, rising to about 95% in frontier counties; private and existing health-centre supply responds to the new schedule and capacity payments.
Obstetric units were initially sized as though every rural birth needed a local minimum-volume unit, which is the opposite of regionalization. Sizing instead on births beyond the 30-minute threshold cut the count from 1,839 to 545 and the rural-generalist requirement from 6,622 to 1,961.
EMS stabilization is the Year 1 flagship: 85% in the first year, requiring no construction and no new clinicians, delivered to about 11,500 agencies that already exist and are failing financially.
Capital replacement begins at launch rather than after the first failure — a blended reserve as a percentage of gross capital stock, ring-fenced so it cannot be raided for operating shortfalls. The claims platform alone carries roughly $6.7B annually in perpetuity, comparable to all physical replacement combined. Federal IT modernization usually fails by building once and funding operations at a fraction of the build.
The model separates completed construction from staffed operational capacity. An unstaffed clinic is not counted as access.
Every large federal IT programme of this shape has failed.
The claims platform is a five-to-seven-year build on the critical path, and the ramp assumes 85% by Year 5. Parallel operation, staged migration, open standards, independent testing and the ability to pay providers during outages are requirements rather than mitigations. This is a genuine single point of failure.
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 inherited capital backlog is not fully modeled.
- Capital replacement enters the design but is not yet in either cost model.