A ten-year full phase-in, with enrollment complete at Year 7. Every question in this category has a yes-or-no answer for a given person or institution on a given date: who is on the old plan and who is on the new one, who pays under which payment method, which institutions lose margin, which specialties take fee reductions, and whose jobs end. Price compression is the fiscal case, which means somebody's income falls — naming who is more honest than calling the same event efficiency. Access density is deliberately not on this clock.
Medicare, Medicaid and ACA subsidies run in full until their fold begins. Meanwhile the claims platform, the Authorities, the AHQB and the EMS network are being built and staffed.
Total spending therefore rises above the current-law path through roughly Year 3, peaks near 19.3% of GDP, and crosses below the current-law path at Year 4. Transition duplication peaks at approximately $146B.
Dual running is unavoidable when the replacement must be proven before the incumbent is switched off. Pretending otherwise produces the pattern where a programme is declared over budget in Year 2 for costs that were always in the plan.
Utilization also rises as suppressed demand enters the system. That is a planned cost, not an implementation failure — it is what the coverage was for.
The Business Transition Surcharges fund the window: a gross-receipts surcharge with a small-business exemption, and an increment on the corporate book minimum, both active in the early years and sunsetting.
The Medicare and Medicaid fold runs across the back half of the enrollment sequence, per state at gate clearance rather than on a fixed national date, so a state whose capacity gates have not cleared does not fold on schedule.
A legacy claims tail persists past the fold: claims incurred under the old system continue to adjudicate after enrollment moves.
The cost surfaces report federal cash outlay, total national health expenditure, household spending, employer spending, state effects and reclassification separately. Moving FEHB or VHA ordinary care between ledgers is not a national saving and is not presented as one.
A programme that costs more for three years before it saves anything will be repealed in year two.
This is why the Year 1 deliverables are chosen for visibility rather than magnitude — EMS stabilization reaches 85% in the first year and requires no construction and no new clinicians. Whether visible early benefit is enough to survive an electoral cycle is genuinely unknown.
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 and remains an uncertainty rather than a hidden assumption.