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.
Four levels, each with one job. The Authority board hires and removes the chief executive and approves the budget. A chartering and oversight office handles charter compliance, catchment assignment and receivership determination. AHQB sets rates and publishes audited cost. Congress writes the statute and appropriates, and adjudicates nothing.
**Publication is the enforcement mechanism before any sanction is.** With hundreds of Authorities reporting standardized cost, an outlier is visible immediately and does not require an investigation to find.
State charitable-trust oversight is the alternative and it does not work at this speed. One recent case took months, arrived after the damage, produced recommendations rather than control, and stopped at the state line. Executive compensation there rose roughly 121% after a merger, from about $2.6M across executives to about $5.7M, with headcount going from 10 to 17 — and identifying it required a journalist reading tax filings. Under standardized published cost it is a line on a dashboard.
The benchmark is also stronger than the one it replaces. A single national system produces a point. Hundreds of Authorities reporting the same fields produce a distribution, and a distribution tells you which end of it a given Authority sits at.
Published quarterly at Authority and facility level: audited cost per service standardized across Authorities, access distribution by service line including median and 90th-percentile travel time, bypass rate, staffing against standard, call burden and vacancy duration, executive compensation, and agency labour as a share of unit hours.
Early warning reads from claims and administrative data rather than from testimony. **Rising bypass rate is the strongest single signal and moves before the finances do** — claims reveal origin-destination flow continuously, and a rising bypass rate identifies a failing facility roughly two years before the balance sheet does. Alongside it: transfer-out rate, days cash on hand, agency labour share, call-schedule gaps at 90 and 180 days, and service-line volume falling faster than catchment population. Any three trending together triggers review.
Receivership runs on the FDIC model rather than bankruptcy. The FDIC does not wait for a buyer; it has standing resolution staff, takes control and reopens. So: a standing federal resolution corps sized for concurrent receiverships, automatic capacity-payment continuation so that governance is replaced while service never is, a resolution reserve funded by assessment on all chartered Authorities, and a 24-month cap after which the Authority is rechartered or its catchment transfers to a neighbour with the assets.
**Triggers include governance breach and access deterioration, not solvency alone.** A solvency-only trigger catches nothing in the case that motivated the design: an Authority that is not insolvent and has breached its fiduciary duty.
Seven percent in receivership at any time reads as a system in permanent partial failure.
Hospital systems fail at approximately that rate now, with no resolution mechanism at all — the difference is that today the failure is discovered late and resolved by closure. A named rate with a standing corps is what converts an invisible failure into a managed 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.
- Resolution-corps sizing depends on the final Authority count, which is itself an output of chartering.