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.
Price compression is the fiscal case, and price compression means somebody's income falls. Naming who is more honest than describing the same event as efficiency.
Hospitals in concentrated markets lose the leverage behind market-power pricing. Procedural specialties take reductions in their differentials. Administrative employment in claims adjudication, prior-authorization review and network management falls substantially. Average clinician compensation falls; no architecture reaches peer cost levels without it.
Commercial plans pay hospitals an average of about 254% of Medicare rates, and nonprofit status does not restrain pricing — tax status governs profit distribution, not pricing behaviour. Clinician compensation runs roughly double peer levels.
Administrative simplification is real and is the smaller lever, about one-sixth of the total. Any proposal reaching peer-nation costs through administration alone is arithmetically wrong.
The reference schedule steps down asymmetrically. Primary care, psychiatry, obstetrics, rural generalism, emergency call and genuine scarcity are held or raised. The reduction falls on routine high-volume procedural differentials, excessive facility rates and self-referred services.
That asymmetry is also the workforce policy. Compressing the spread redirects entering cohorts more effectively than any scholarship programme, and splitting the physician lobby is the route to passage.
Clinicians receive something in exchange: liability reform with guideline adherence as an affirmative defence, abolition of prior authorization, collapse of administrative burden, and training funded as public infrastructure rather than trainee debt.
Administrative spending falls roughly 17% — about $245B. That is employment, concentrated in claims adjudication and utilization review, and these are jobs the architecture deliberately eliminates.
Prior-authorization abolition in Year 1 is the sharpest single displacement in the program. It removes an entire occupational category before any conversion tranche has enrolled, on the order of 150,000 to 300,000 jobs. Retraining into care coordination and authority administration has to be funded **before** the function is abolished, not after. Sequencing it the other way is how a defensible reform acquires an indefensible first year.
Access guardrails pause or reverse compression when vacancy, waiting, transfer delay, procedure backlog, locum dependence, clinician exit or adverse outcomes cross thresholds. The purpose is to preserve required capacity, not every incumbent income.
The AMA, the AHA and the nursing unions have never lost this fight.
Correct, and this is the highest-probability failure mode in the program. Under a halved glide path the program costs more than current law — a sign reversal rather than a narrowed advantage. The asymmetric schedule exists specifically to split the coalition that would otherwise be unanimous.
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.
- Exit is fast and redistribution is slow: specialist capacity falls in years 2–5 while primary-care capacity rises in years 10–15. Capacity lost in the gap is routed into the access-adjusted metric rather than booked as a saving.
- The displaced-administrative-worker transition is named but not designed.