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.
Three clocks run, and merging them is the error earlier drafts made.
**The payer moves in single-digit years.** Medicare went from enactment to operating in eleven months by paying existing providers through existing intermediaries — it built no institutions. Enrollment here completes at Year 7 inside a ten-year full phase-in.
**The institution takes a generation.** TVA took five years to matter and fifteen to finish. Authority chartering from existing entities runs two to three years; a network at national coverage is a twelve-to-twenty-year horizon.
**Access has no completion date at all**, and is reported as a distribution rather than a percentage.
Tranches are defined by employer size and average payroll, and by region using service density and COMPASS shortage score. Every cell is capacity-gated: no tranche goes live if it would degrade access, wait times or quality, and the gate can hold a cell back.
Coverage expansion into a supply-constrained system produces waiting lists. Sequencing exists so that demand arrives where capability already is.
Ten years is reachable because of regional control rather than despite it. The Authorities convert existing facilities before constructing, so capital is $94B across the decade — 0.78% of national health expenditure, with peak-year spend about a quarter of the healthcare construction the United States already puts in place annually. Construction binds nowhere. Workforce binds.
Tranches phase who enrolls when, never the rate. When a tranche goes live it pays the full payroll rate from its first day; there is no discounted on-ramp and no partial-rate period.
The currently uninsured enroll first — the largest coverage gap, and the population with the heaviest out-of-pocket exposure. Federal employees follow as FEHB terminates. High-compensation employer plans move next, which is also where the uncapped payroll base does the most work. Middle and small employer plans and the Medicare and Medicaid fold complete the sequence, per state at gate clearance.
Legacy Medicare and Medicaid run in full until their fold begins, which is why total spending rises above the current-law path in the early years before crossing below it. That overlap is a planned cost, not an implementation failure, and the Business Transition Surcharges exist to fund it.
- Who pays
- Enrollment date and payment-structure change are the same event for a given population.
- Access as a distribution
- Being enrolled is not the same as having the unit down the road. The two are reported separately.
Ten years requires three presidential terms. The ACA required one and nearly did not survive it.
The Year 1–3 visible-benefit package exists to buy runway: EMS stabilization at 85% in the first year, medical-debt relief, a hard out-of-pocket cap, drug-price action, and the end of surprise billing and prior authorization. It may be insufficient. This is the highest-probability political failure mode and it is not solved by design.
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 claims platform is a five-to-seven-year build and sits on the critical path.