Universal HealthcareBy NextBestFit
Part 2 · Changes by phase

Every change, in order

The concrete changes required by every chosen solution path, grouped by the phase in which they happen. Choices are drafts awaiting review, so this list changes when a pick is flipped.

Chosen paths
144
Concrete changes
272
Phases
6
Draft
Every pick behind this list is unreviewed. See the review ledger.

Phase 0: Preparation

Before coverage starts · 42 paths · 90 changes · phase detail

Before anyone moves to the new program: fix the worst problems in today's system (automatic enrollment of the uninsured, denials, prior authorization, medical debt, surprise bills, drug middlemen), start the long-lead workforce and data work, and settle how state money keeps flowing.

Automatic enrollment with free default coverageFor: Tens of millions of people have no coverage
  1. Allow IRS, SSA, and state agencies to share data to identify uninsured residents
  2. Enroll uninsured people automatically in Medicaid or a zero-premium marketplace plan
  3. Fully fund zero-premium plans for everyone below a set income
  4. Allow retroactive coverage for anyone who arrives at a hospital uninsured
Continuous eligibility (12-month or multi-year) in Medicaid and CHIPFor: People lose coverage when their life changes (churn)
  1. Require 12-month continuous eligibility for adults in Medicaid and multi-year eligibility for children up to age 6
  2. Use automated renewals with tax and benefit data (ex parte renewals)
Buy and cancel existing medical debtFor: Medical debt affects about 100 million people
  1. Appropriate funds to buy medical debt from debt buyers and hospitals
  2. Contract with nonprofits to buy and forgive debt
  3. Notify forgiven patients and credit bureaus
Ban medical debt from credit reports and limit collectionsFor: Medical debt affects about 100 million people
  1. Ban medical debt on credit reports nationally
  2. Cap interest on medical debt at 0–3%
  3. Ban lawsuits, liens, and wage garnishment for medical debt
  4. Require charity-care screening before collections
Enforce price transparency rulesFor: Patients can't know prices in advance
  1. Raise penalties for transparency non-compliance
  2. Standardize file formats and require patient-facing price estimates
Set a default out-of-network rate instead of arbitrationFor: Surprise billing and a runaway arbitration system
  1. Set out-of-network payment at a fixed percentage of Medicare
  2. End the independent dispute resolution process
  3. Include ground ambulances
Regulate denials: reporting, penalties, and fast independent appealsFor: Claim denials
  1. Require insurers to publish denial rates by service and reason
  2. Penalize insurers for denials overturned on appeal
  3. Create fast external appeals (72 hours for urgent care)
Gold-carding and automatic approvalsFor: Prior authorization delays and blocks care
  1. Exempt clinicians with high approval rates from prior authorization
  2. Require electronic real-time decisions
  3. Ban prior authorization for routine and chronic care
Fix Medicare Advantage paymentsFor: Medicare Advantage overpayments and coding intensity
  1. Use two years of diagnosis data for risk scores
  2. Exclude diagnoses from home visits and chart reviews
  3. Expand RADV audits with extrapolated recoveries
Regulate PBMs: delink pay from drug prices, ban spread pricingFor: Pharmacy benefit managers profit from opaque drug pricing
  1. Delink PBM pay from drug prices (flat fees)
  2. Ban spread pricing
  3. Require 100% rebate pass-through
  4. Ban PBM ownership of pharmacies they steer patients to
Stronger antitrust: block mergers and undo someFor: Hospital and physician consolidation raises prices
  1. Fund FTC and DOJ health-care enforcement
  2. Review small physician-practice acquisitions
  3. Allow retrospective challenges to completed mergers
Limit private equity ownership and require disclosureFor: Private equity roll-ups in medicine
  1. Require ownership disclosure for all providers
  2. Ban corporate control of medical decisions
  3. Limit sale-leasebacks
  4. Make owners liable for stripped assets
Site-neutral paymentFor: Facility fees: the same service costs more in a hospital-owned building
  1. Pay hospital outpatient departments the same as physician offices for the same services
  2. Fund standby capacity separately
Tie nonprofit tax exemption to community benefitFor: Executive pay and nonprofit status
  1. Set minimum community-benefit spending for nonprofit hospitals
  2. Tie executive pay to community benefit
Limit patent thickets and evergreeningFor: Patent thickets and evergreening delay generics
  1. Limit the number of patents asserted per drug
  2. End exclusivity extensions for minor changes
  3. Ban pay-for-delay settlements
Mail-order and telepharmacyFor: Pharmacy closures and pharmacy deserts
  1. Allow remote pharmacist supervision in all states
  2. Cover mail delivery
Convert to emergency and outpatient centersFor: Rural hospital closures
  1. Expand Rural Emergency Hospital eligibility
  2. Fund transfer agreements and transport
Expand midwives and birth centersFor: Maternity care deserts
  1. License certified midwives in all states
  2. Cover birth centers
  3. Require transfer agreements
Loan forgiveness and service obligationsFor: Health professional shortage areas
  1. Expand National Health Service Corps
  2. Offer free training for service commitments
Permanent telehealth coverageFor: Health professional shortage areas
  1. Cover telehealth at parity permanently
  2. Create interstate telehealth licensing
Fund more residency slotsFor: Physician shortage, especially in primary care
  1. Fund more residency slots, prioritizing primary care and rural sites
Easier licensing for foreign-trained physiciansFor: Physician shortage, especially in primary care
  1. Create supervised licensing pathways for experienced foreign physicians
Tuition-free medical and nursing schoolFor: Medical education debt shapes specialty choice
  1. Fund tuition for medical and nursing school
  2. Tie to service obligations
Expand nursing schools and faculty payFor: Nursing and direct-care shortages and burnout
  1. Fund nursing faculty salaries
  2. Fund clinical placements
Fund scribes and AI documentationFor: Clinician burnout from paperwork and EHR work
  1. Pay for scribes or AI documentation tools
Full practice authority for NPs, PAs, pharmacists, dental therapistsFor: Scope-of-practice limits waste capacity
  1. Grant full practice authority to NPs, PAs, pharmacists, dental therapists nationally
12-month postpartum coverage and home visitsFor: High maternal mortality and postpartum coverage gaps
  1. Guarantee 12-month postpartum coverage
  2. Fund nurse home visits
Hospital safety bundles and review committeesFor: High maternal mortality and postpartum coverage gaps
  1. Require hemorrhage and hypertension protocols in all hospitals
  2. Fund maternal mortality review committees
Standardize across many payersFor: About $1 trillion a year in administrative cost
  1. Require identical forms, codes, prior-auth rules, and credentialing across payers
Stepped care and integration into primary careFor: Mental health care is hard to get
  1. Allow self-referral to talking therapies
  2. Fund collaborative care in primary care
  3. Fund crisis lines
Easy access to medication treatmentFor: Overdose crisis and gaps in addiction treatment
  1. Allow any clinician to prescribe buprenorphine
  2. Allow methadone in pharmacies and primary care
Harm reduction servicesFor: Overdose crisis and gaps in addiction treatment
  1. Fund naloxone, drug checking, and supervised consumption sites
Keep means testing, but expand home careFor: Long-term care requires spending down to poverty
  1. End HCBS waitlists
  2. Raise Medicaid asset limits
Tighter hospice oversightFor: Hospice growth, for-profit entry, and fraud
  1. Use enrollment moratoria in high-fraud areas
  2. Audit long stays
  3. Require ownership disclosure
Free preventive care and vaccinesFor: Prevention and public health are underfunded
  1. Cover preventive services without cost sharing
Mandatory data-sharing standardsFor: Records don't follow patients
  1. Enforce FHIR APIs
  2. Ban information blocking
Mandatory security standards and backup payment systemsFor: Cyberattacks can halt payments and care
  1. Set minimum security standards
  2. Create backup payment systems
Strong health privacy lawFor: Health privacy
  1. Extend privacy protections to apps and data brokers
Build capacity before demand risesFor: Longer waits if demand grows faster than capacity
  1. Expand workforce and facilities before coverage starts
Phased transition in wavesFor: Transition disruption: jobs, companies, and familiar coverage
  1. Move groups in waves over 4+ years
Measure outcomes by clinician type and adjust scopeFor: Quality concerns when non-physicians practice independently
  1. Publish outcomes by clinician type
Supervised transition period before independenceFor: Quality concerns when non-physicians practice independently
  1. Require supervised hours before independence

Phase 1: Enactment & build

Year 0: the 18 months between signing and first coverage · 54 paths · 98 changes · phase detail

Stand up the agency, the money, the systems, the rules, and the people, so that coverage day works.

Single public payer for everyoneFor: Tens of millions of people have no coverage
  1. Create a national health program (or expand Medicare) covering every resident, with automatic enrollment from tax, Social Security, and immigration records
  2. Prohibit private insurance from selling coverage that duplicates the public benefit
  3. Fold Medicare, Medicaid, CHIP, ACA marketplace subsidies, FEHB, and TRICARE civilian coverage into the program; decide whether the VA and IHS stay separate
  4. Replace employer premiums, employee premiums, and state Medicaid spending with dedicated taxes and maintenance-of-effort payments
  5. Build one national enrollment, eligibility, and claims-payment system with a member card
  6. Set one national fee schedule and/or hospital budgets, with regional adjustments
  7. Amend ERISA so employer self-insured health plans end for covered services
  8. Fund a worker transition program for insurer, broker, and billing staff
No cost sharing at the point of careFor: Underinsurance: covered, but can't afford to use it
  1. Set cost sharing to zero for all covered services by law
  2. Remove deductibles and coinsurance from claims systems
  3. Ban balance billing by participating providers
Replace premiums with progressive taxesFor: Premiums are a large, flat, hidden tax on wages
  1. End employer and employee premiums for covered services
  2. Enact replacement taxes (payroll, income, or both) at published rates
  3. Publish household calculators showing net change
One public price list for every serviceFor: Patients can't know prices in advance
  1. Publish one national fee schedule and all hospital budgets
  2. Ban confidential negotiated rates for covered services
Public coverage rules with clinician-led reviewFor: Claim denials
  1. Publish one national coverage rulebook
  2. Create an independent appeals board with clinician reviewers
Public administration with a cost targetFor: Insurer overhead and profit
  1. Create a public administering agency with a published admin-cost target
  2. Fund customer service and integrity staff
Public drug formulary and direct pricingFor: Pharmacy benefit managers profit from opaque drug pricing
  1. Create a national drug formulary and negotiating agency
  2. Pay pharmacies a published dispensing fee plus acquisition cost
  3. End PBM contracts for covered drugs
All-payer rate settingFor: U.S. prices are far higher than in other countries
  1. Create a rate-setting commission
  2. Require every payer to pay commission rates
  3. Ban billing above commission rates
  4. Publish rates and methodology
Cap commercial prices at a multiple of MedicareFor: U.S. prices are far higher than in other countries
  1. Cap commercial payments at a set multiple of Medicare
  2. Phase the cap in over several years
Make consolidation irrelevant to priceFor: Hospital and physician consolidation raises prices
  1. Apply uniform rates regardless of system size
Remove the profit opportunity through rate settingFor: Private equity roll-ups in medicine
  1. Apply uniform rates and end out-of-network billing
National negotiation for all drugsFor: Brand-name drug prices far above production cost
  1. Extend national negotiation to all drugs for all payers
  2. Use international prices and added-benefit assessments as benchmarks
  3. Apply an excise tax or exclusion if manufacturers refuse to negotiate
Public manufacturing of off-patent drugsFor: Brand-name drug prices far above production cost
  1. Fund a public or nonprofit manufacturer for off-patent drugs with high prices or shortages
  2. Guarantee volume purchases
Expand public R&D fundingFor: R&D is funded by high prices, which ties innovation to unaffordability
  1. Increase NIH and late-stage trial funding
  2. Create a public clinical-trial network
Value-based prices that reward real innovationFor: R&D is funded by high prices, which ties innovation to unaffordability
  1. Create a health-technology-assessment agency
  2. Tie negotiated prices to added-benefit ratings
Pay more for reliable supplyFor: Drug shortages of cheap, essential generics
  1. Pay premiums for redundant, quality-rated supply chains
  2. Use long-term contracts with minimum volumes
Fair dispensing fees and support for rural pharmaciesFor: Pharmacy closures and pharmacy deserts
  1. Set a transparent dispensing fee covering costs
  2. Add rural pharmacy payments
Higher pay in shortage areasFor: Health professional shortage areas
  1. Raise the shortage-area fee bonus
Raise primary care pay relative to specialtiesFor: Physician shortage, especially in primary care
  1. Shift fee-schedule dollars from procedures to primary care
  2. Change the fee-update committee to include more primary care
Global budgets for hospitalsFor: U.S. prices are far higher than in other countries
  1. Negotiate annual operating budgets with each hospital
  2. Fund capital separately
  3. Adjust budgets for population, age, and service mix
  4. Remove per-claim billing for inpatient and outpatient hospital care
Fee-for-service at public fee scheduleFor: U.S. prices are far higher than in other countries
  1. Set one national fee schedule
  2. Revise fees every two years
  3. Add volume controls by specialty
Capitation for primary care and integrated systemsFor: U.S. prices are far higher than in other countries
  1. Pay primary care practices per enrolled patient
  2. Risk-adjust payments
  3. Set quality and access requirements
Shift spending toward primary careFor: Worse outcomes than peer countries despite the highest spending
  1. Set a target share of spending for primary care
  2. Report primary care spending annually
Mandatory error reporting and learning systemFor: Medical errors and poor care coordination
  1. Create a national no-blame adverse-event reporting system
  2. Create an independent patient-safety investigation agency
Equity-adjusted fundingFor: Racial, income, and geographic disparities
  1. Add deprivation-index payments to provider rates
Rely on universal coverage and uniform ratesFor: Racial, income, and geographic disparities
  1. Pay one rate for every patient regardless of former coverage
One claims system and standard rulesFor: About $1 trillion a year in administrative cost
  1. Build one national claims system with standard codes
  2. Pay claims in real time
Worker transition programFor: Simplifying billing would displace hundreds of thousands of workers
  1. Fund wage replacement, retraining, and placement for displaced workers
Redeploy billing staff to care coordinationFor: Simplifying billing would displace hundreds of thousands of workers
  1. Hire displaced billing staff into navigation and scheduling roles
Evidence-based coverage decisionsFor: Low-value care and overtreatment
  1. Create an evidence-review agency
  2. Stop covering services proven ineffective
Pre-payment analytics and auditsFor: Fraud and improper payments
  1. Run real-time fraud analytics on all claims
  2. Fund audits and prosecution
Stricter provider enrollmentFor: Fraud and improper payments
  1. Require background checks and site visits for new providers
  2. Use moratoria in high-fraud categories
Pay mental health clinicians at parityFor: Mental health care is hard to get
  1. Raise mental health rates to parity with medical care
Dedicated public health fundingFor: Prevention and public health are underfunded
  1. Set a fixed share of health spending for public health
National health record and patient IDFor: Records don't follow patients
  1. Create a national health record and patient ID
Redundant public infrastructureFor: Cyberattacks can halt payments and care
  1. Run claims on redundant public infrastructure with offline fallback
Opt-out of national record sharingFor: Health privacy
  1. Create an opt-out of national record sharing
Dedicated trust fund with automatic indexingFor: Chronic underfunding by government budgets
  1. Create a health trust fund with dedicated revenue
  2. Index funding to costs and demographics
Separate public capital budget, planned regionallyFor: Under-investment in equipment and facilities
  1. Create a separate capital budget allocated by regional need
Cover new treatments at launch, then reassessFor: Slower access to new drugs and technology
  1. Cover new drugs at launch with provisional prices
  2. Reset prices after evidence review
Recycle part of drug savings into researchFor: Slower access to new drugs and technology
  1. Dedicate a share of drug savings to research
Strict opt-out rules for cash-only practiceFor: Providers leave, retire, or go cash-only if pay drops
  1. Require opted-out clinicians to stay out for a set period
Fixed budget share for program integrityFor: One payer becomes one target
  1. Reserve a share of admin spending for program integrity
Regional administrators under national rulesFor: One payer becomes one target
  1. Split claims processing among regional administrators
A mix of payroll, income, and redirected spendingFor: Replacing premiums with taxes
  1. Combine redirected spending, employer contributions, and income-based contributions
Phase in employer taxes for small and low-wage firmsFor: Employer health taxes can lower wages at firms that never offered coverage
  1. Phase in employer taxes for small and low-wage firms
Drop point-of-care charges entirelyFor: Copays keep billing systems alive and still deter poorer patients
  1. Remove all point-of-care charges
Independent, transparent coverage body with appealsFor: Central coverage decisions can feel like rationing
  1. Create an independent coverage agency with public meetings and appeals
Clinician-led exceptions with fast reviewFor: Central coverage decisions can feel like rationing
  1. Create a fast clinician exception process
Blended payment: part capitation, part fee-for-serviceFor: Paying a fixed amount per patient rewards doing less
  1. Blend capitation with fees
Price floors and supply guarantees for essential productsFor: Price limits can cause shortages, launch delays, or exits
  1. Set price floors and long-term contracts for essential products
Independent peer review with set-asides for high-risk ideasFor: Government chooses which research gets funded
  1. Keep peer review
  2. Set aside funds for high-risk research
States administer under national rulesFor: States lose control and budgets shift between levels of government
  1. Let states administer under national rules
Maintenance-of-effort payments from statesFor: States lose control and budgets shift between levels of government
  1. Require state maintenance-of-effort payments

Phase 2: Wave 1: seniors, near-seniors, and children

Year 1 · 8 paths · 16 changes · phase detail

Cover the 176 million people who are 55+ or under 19, upgrade Medicare into UHP, and prove the system works at scale.

Every licensed provider is in-networkFor: Narrow networks and out-of-network surprises
  1. Require the payer to pay any licensed, enrolled provider at the standard rate
  2. Create one national provider enrollment and credentialing system
Prevent new debt by ending point-of-care billsFor: Medical debt affects about 100 million people
  1. Eliminate point-of-care charges for covered services
  2. Wind down hospital patient-collections departments
Eliminate prior authorization except for a short listFor: Prior authorization delays and blocks care
  1. Limit prior authorization to a published short list
  2. Fund post-payment audits
Fold Medicare Advantage into the public programFor: Medicare Advantage overpayments and coding intensity
  1. Stop new Medicare Advantage enrollment
  2. Move enrollees into the public plan on a fixed date
  3. Add dental, vision, hearing to the public plan
Global budgets for rural hospitalsFor: Rural hospital closures
  1. Give rural hospitals fixed annual budgets
  2. Adjust for service changes
Standby payments to keep labor units openFor: Maternity care deserts
  1. Pay rural labor units a fixed readiness payment
Cover ambulance and non-emergency transportFor: Getting to care: transportation and ambulances
  1. Cover ground ambulance and non-emergency rides for everyone
Universal long-term care insuranceFor: Long-term care requires spending down to poverty
  1. Create universal long-term care insurance
  2. Fund through a dedicated contribution
  3. Create need-based assessments

Phase 3: Waves 2 & 3: working-age adults

Years 2–3 · 8 paths · 11 changes · phase detail

Bring adults 35–54 into UHP, convert long-term care into an entitlement, and wind down the private insurance industry in an orderly way.

Public review of hospital budgetsFor: Executive pay and nonprofit status
  1. Include admin and executive costs in hospital budget review
  2. Publish executive pay
Publicly funded EMS as essential serviceFor: Getting to care: transportation and ambulances
  1. Fund EMS by budget like fire departments
  2. Ban ambulance bills for covered services
Pay for activity on top of budgetsFor: Longer waits if demand grows faster than capacity
  1. Pay extra for procedures beyond baseline volume
Phase rate changes in over several yearsFor: Providers leave, retire, or go cash-only if pay drops
  1. Phase rate changes over several years
Let people choose among public care organizationsFor: Losing the choice of health plan and insurer competition
  1. Let people choose among public care organizations paid by capitation
Budgets adjust automatically for population, age, and volumeFor: Fixed budgets can ration care
  1. Adjust budgets for population, age, and volume
Base budget plus activity paymentsFor: Fixed budgets can ration care
  1. Pay base budgets plus activity payments
Risk adjustment plus outcome monitoringFor: Paying a fixed amount per patient rewards doing less
  1. Risk-adjust capitated payments
  2. Monitor access and outcomes

Phase 4: Wave 4: everyone

Year 4 · 14 paths · 28 changes · phase detail

Cover the remaining adults, end job-based insurance, fold Medicaid into UHP, and switch every tax to its full rate.

Coverage tied to residence, not job or incomeFor: People lose coverage when their life changes (churn)
  1. Base eligibility only on residence
  2. Remove income and employment checks from enrollment
Decouple coverage from employmentFor: Job lock: people stay in jobs to keep insurance
  1. End the tax exclusion for employer health premiums (or make it irrelevant by ending employer plans for covered services)
  2. Require employers to report premium savings and pass them into wages for a transition period
Cover all residents regardless of immigration statusFor: Immigrants and mixed-status families fall through gaps
  1. Define eligibility by residence, with proof via lease, utility, school, or employment documents
  2. Separate health enrollment data from immigration enforcement by law
  3. Fund outreach in multiple languages
Cover the territories in the national program on the same terms as the statesFor: U.S. territories get capped, lower federal health funding
  1. Define program residency to include all five territories
  2. Remove the territories' Medicaid caps and fixed matching rates from federal law
  3. Make Medicare Part B enrollment automatic in Puerto Rico
  4. Set geographic payment adjustments for the territories
Eliminate out-of-network statusFor: Surprise billing and a runaway arbitration system
  1. Eliminate network status for covered services
  2. Ban balance billing by any provider that bills the program
Cut documentation and billing burdenFor: Clinician burnout from paperwork and EHR work
  1. Simplify billing codes and documentation rules
  2. Cut quality-reporting programs
Every person registered with a primary care homeFor: Medical errors and poor care coordination
  1. Register every resident with a primary care practice
  2. Require referrals for most specialist care
Cover dental, vision, and hearing fullyFor: Dental, vision, and hearing are mostly uncovered
  1. Add dental, vision, and hearing to the standard benefit
Legal wait-time guaranteesFor: Longer waits if demand grows faster than capacity
  1. Set legal maximum waits by service
  2. Let patients go elsewhere at payer cost when exceeded
Allow supplemental only (non-covered items)For: Two-tier care: a private fast lane for those who can pay
  1. Allow private insurance only for non-covered items
Private supplemental plans for extrasFor: Losing the choice of health plan and insurer competition
  1. Allow supplemental plans for extras
Automatic exemptions and annual collection through taxesFor: Copays keep billing systems alive and still deter poorer patients
  1. Create a charge ledger
  2. Cap charges by income
  3. Settle annually on tax returns
Waiting-time guarantees as a backstopFor: Fixed budgets can ration care
  1. Charge late hospitals for care elsewhere
Residence period before eligibilityFor: Covering all residents raises cost and migration concerns
  1. Require a residence period before full coverage
  2. Cover emergencies, children, and pregnancy immediately

Phase 5: Stabilize & govern

Year 5 onward · 18 paths · 29 changes · phase detail

Keep costs growing no faster than the economy, keep waits within the guarantee, keep the program honest, and decide with evidence whether to change the core design.

Prize funds and advance market commitmentsFor: R&D is funded by high prices, which ties innovation to unaffordability
  1. Create a prize fund for set goals
  2. Set advance market commitments for antibiotics
National stockpile and onshore productionFor: Drug shortages of cheap, essential generics
  1. Maintain buffer stocks of essential drugs
  2. Fund domestic production of active ingredients
Minimum nurse staffing ratiosFor: Nursing and direct-care shortages and burnout
  1. Set nurse-to-patient ratios by unit
  2. Fund ratios through rates
Invest outside health careFor: Worse outcomes than peer countries despite the highest spending
  1. Fund housing, nutrition, and public-health programs from health savings
No-fault compensation for medical injuryFor: Malpractice system: slow, costly, and drives defensive medicine
  1. Create a no-fault injury compensation fund
  2. Replace most malpractice lawsuits
  3. Separate discipline from compensation
Feedback and clinician nudgesFor: Low-value care and overtreatment
  1. Report low-value care rates to clinicians
  2. Add EHR alerts
Minimum staffing and financial transparencyFor: Nursing home understaffing and quality
  1. Set minimum staffing
  2. Require disclosure of related-party payments
  3. Set minimum spending on care
Shift to small homes and home careFor: Nursing home understaffing and quality
  1. Fund small-house models and home care
Let health budgets pay for housing and foodFor: Housing, food, and transportation drive health, but health care isn't designed for them
  1. Allow health budgets to pay for housing support, meals, and rides
Spending-growth target tied to GDP, reviewed publiclyFor: Chronic underfunding by government budgets
  1. Create an independent board with a spending-growth target
  2. Require public justification for departures
Lower costs for clinicians, not only payFor: Providers leave, retire, or go cash-only if pay drops
  1. Reduce billing overhead, malpractice costs, and debt for clinicians
Hold the single payer to service standardsFor: Losing the choice of health plan and insurer competition
  1. Publish service metrics
  2. Create an ombudsman with enforcement power
Monitor supply and adjust prices quicklyFor: Price limits can cause shortages, launch delays, or exits
  1. Track launches and discontinuations
  2. Raise prices when supply falls
Phase mandates in with workforce growth, funded in ratesFor: Staffing mandates raise costs and may close facilities
  1. Phase staffing rules with workforce growth
Hardship waivers for shortage areasFor: Staffing mandates raise costs and may close facilities
  1. Allow time-limited hardship waivers
Standardized needs assessment and tiered benefitsFor: Covering long-term care can pull unpaid family care into the paid system
  1. Create independent needs assessment with tiered benefits
Cash benefit option for family caregiversFor: Covering long-term care can pull unpaid family care into the paid system
  1. Offer a cash benefit for family caregivers
Independent audits and few, simple measuresFor: Targets and quality metrics invite gaming
  1. Audit a short list of measures