Coverage authority, payment authority, audit and appeals sit in separate bodies, because concentrating them would make a coverage mistake, a payment mistake and a governance mistake mutually reinforcing. The cost brake runs in two stages and both read access-adjusted spending, so a fall caused by undelivered care never registers as a saving. Prior authorization is abolished and replaced by retrospective, collective review. Durability is engineered: universality, mandatory appropriation, ring-fenced capital, insulated rate-setting.
Durability is designed rather than assumed. Programs for the poor become poor programs: Medicare has survived sixty years and every serious attempt to reduce it, while Medicaid has been reduced repeatedly. The difference is who is enrolled.
Everyone is in the floor — every income, every state, every member of Congress, every federal official.
Universality is the deepest argument against eligibility spend-down and against means-testing any clinical benefit. A benefit the powerful also receive is a benefit the powerful defend.
The Indian Health Service is the cautionary case. It has the same structure as the VHA and the opposite result, and the difference is the appropriation.
Floor benefits and Authority operating budgets are mandatory spending on permanent appropriation, not subject to annual appropriation risk or shutdown interruption.
Capital is separately protected. Public systems die by deferred maintenance long before anyone votes to close them, so the replacement reserve is sized as a percentage of stock and cannot be raided to cover operating shortfalls.
Rate setters and AHQB members serve fixed terms with removal only for cause. Political officials may change law and budgets; they may not direct an individual coverage case.
A Benefit Sufficiency and Expansion Report is issued annually. It asks whether existing benefits are actually available, whether access standards are met, whether workforce is adequate, whether unresolved demand is declining, whether the conservative fiscal corridor is intact, and whether a proposed addition meets evidence standards. No benefit expands merely because cash savings appear.
The constituency is deliberate. Capacity payments create thousands of communities whose emergency department, ambulance service and obstetric unit exist because of this program. Service-obligation scholarships create a generation of publicly financed clinicians. Authorities create a distributed public workforce. These are the people who defend the program in 2050.
Financing is countercyclical by construction: Medicaid's state-match structure reduces coverage precisely when unemployment creates need, and federal financing on a permanent appropriation does not.
Designing a program to be hard to repeal is an argument against democratic accountability.
The mechanisms here are ordinary and already in use — mandatory appropriation, fixed terms, ring-fenced capital. Congress retains full authority to change the law. What it cannot do is defund the program quietly through the appropriations cycle while claiming the benefit still exists.
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.
- Ten years spans three presidential terms, and no design feature solves that.