Every design choice buys one outcome and costs another, and the second half is stated rather than hidden. The highest-probability failure is partial price reform with full benefit expansion — a reversal of sign rather than a narrowed advantage. Geography imposes irreducible cost that no payment design removes; the correct category is universal service obligation. And nothing here follows automatically from single-payer financing: thirteen separate statutes are named, because assumed preconditions are how programs discover in year three that a load-bearing law was never passed.
The reform changes incentives. It does not abolish scarcity or error.
Cross-method arbitrage persists — publishing risk-adjusted total cost of care by lane makes it visible, not impossible. Capacity rates may be set too high or too low. Global budgets may encourage queues. Prospective payment may encourage stinting. Fee schedules may still reward marginal volume.
Geography imposes irreducible cost. A frontier ambulance, obstetric unit or air base may never appear efficient per encounter, and no payment design makes it so. The correct category is universal service obligation, alongside rural electrification and postal delivery — and saying that is more honest than pretending a 900-square-mile county's ambulance service pays for itself.
Administrative savings are also real but smaller than commonly claimed. Providers still document, code and bill, even to a single payer.
Some unnecessary care will be delivered and paid for. That is the accepted price of abolishing prior authorization, and retrospective review always finds the pattern after the first instance.
Capacity payment invites thin service, requiring audited staffing and readiness standards with clawback — at real administrative cost that partially offsets savings claimed elsewhere. Capacity-payment rate-setting is itself an unsolved administrative problem: the cost-report infrastructure does not exist in usable form, and existing Medicare cost reports are gamed.
Dental remains largely uncovered beyond prevention for the first decade. Authorities will not be uniformly competent. The floating point value transfers volume risk to clinicians and may be the first mechanism traded away.
Nothing here follows automatically from single-payer financing. Each of these is a separate fight: federal medical liability preemption with administrative compensation; repeal of the quality-adjusted-life-year prohibition; the AHQB enabling act; repeal of the physician self-referral exceptions; removal of satisfaction scoring from procedural payment; Medicaid replacement and state clawback; graduate medical education cap repeal and geographic reallocation; federal shortage-area licensure and scope authority; all-payer rate authority; Authority chartering with permanent appropriation; reproductive access and preemption; employer health exclusion repeal; and FEHB termination.
A named dependency ledger is the point. Assumed preconditions are how programs discover in year three that a load-bearing statute was never passed.
Thirteen separate legislative fights is not a plan, it is a wish list.
It is a disclosure. The alternative framing — a single comprehensive bill — hides the same thirteen fights inside one vote and makes the whole architecture hostage to the weakest of them. Sequencing them separately at least allows partial progress to be real progress.
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 supply-response elasticities are first guesses and are contested.
- The uncertainty analysis is a response surface rather than a structural re-run, so its bands understate structural uncertainty.