The American Healthcare Quality Board publishes national coverage indications; a service inside an indication is paid on the clinician's attestation. Congress sets the ethical frame and the numbers encoding it, and AHQB applies them — an unelected board choosing a value threshold would be illegitimate, while the same board applying one set by statute is not. The cost-effectiveness corridor governs end-stage life-prolonging therapy only; the rest of the floor is a clinical determination on evidence of benefit, with price disciplined by procurement and negotiation.
The floor pools unbearable cost, maintains functional capacity, mitigates loss prevention, and maximizes intergenerational fealty. Those four clauses are the test, applied in both directions — a floor that only ever expands is not governed by a principle, and the annual physical for healthy adults satisfies none of them.
The corridor governs interventions whose sole purpose is delaying death. Everything else — the great majority of the floor — is a clinical determination on evidence of benefit, the way FDA approval and ordinary coverage policy already work. No utility weighting, no threshold, no corridor.
Within the narrow class, three conditions govern: no advance directive to the contrary, no patient objection, and demonstrated cost efficacy in trial. The corridor itself moves: when the cost brake engages, the line moves with it.
A corridor applied to all of medicine would put a price test on a hip replacement, on insulin, on a child's asthma care. That is both wrong and politically indefensible, and it is the version every opponent assumes.
Narrowing the scope is therefore the strongest available answer to the death-panel attack — stronger than any carefully worked example. The corridor does not touch the care almost anyone will ever receive.
Making the corridor movable rather than fixed is the second choice worth defending. A fixed threshold is a permanent statement about what a life-year is worth. A threshold that moves with what the system can afford is a budget instrument, which is what it actually is.
Congress sets the ethical frame and the numbers encoding it; AHQB applies them and publishes its reasoning. Congress does not adjudicate individual technologies.
Disability-neutral safeguards apply inside the class. Health state attributable to the condition under treatment is measured; anything else is set at the population norm. A wheelchair user with a terminal illness is scored on the illness, not the wheelchair. Productivity, earning capacity and caregiving burden are excluded from every determination. Disability organizations hold standing to petition and permanent seats on the methods committee.
Rarity permits evidentiary flexibility — smaller studies, validated surrogate endpoints, registries, outcomes-based payment. It does not raise the value of a health year, and there is no rarity modifier.
Marginal and high-cost treatment is not part of the entitlement at all. The floor covers what satisfies the ordinary evidence and value rules; nothing competes with ordinary care for a remainder. If Congress wants a humanitarian exception it is a separate fixed appropriation outside the entitlement, allocated among patients by AHQB on published clinical criteria the way donor organs are — no entitlement for any patient or manufacturer, no effect on the floor's price ceiling, and exhausted when it is exhausted.
Budget impact is a separate test, because cost-effectiveness and affordability are different questions. A cheap drug used by five million people is a larger fiscal event than an expensive drug used by five hundred.
Attribution creates a new discretionary surface: someone decides what belongs to the disability and what belongs to the disease.
The sharpest objection in the package, and it lands on the same ground the disability-rights case occupies. Attribution determinations are published, and the standing already granted to disability organizations extends to challenging them. The alternative — valuing every extended life-year identically regardless of state — answers the objection by losing the ability to distinguish a high-function extension from a low-function one.
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.
- Price discipline outside the narrow class comes from procurement, international reference pricing and negotiation, with budget impact as backstop. This must be stated affirmatively or the narrowing reads as an absence.
- The public surface states the scope and works no example: every in-scope example is barred by the no-death-panel rule, and every permissible example is out of scope.