Part 1 · Solution paths

Every path, so you can decide

Each problem has two or more possible solution paths, each with pros, drawbacks, who gains, who loses, how to mend the losers, and where it has been tried. Many paths create new problems, which have their own subpaths. Nothing here is chosen yet.

Solution paths

187

Problems

Problems created by paths

Decided

187 / 187

How to read the relationships

Addresses / also helps: problems the path fixes (475 links in total across paths).
Creates or worsens: new problems the path causes. Expand “creates” below to see the subpaths that answer them.
Requires: another path that must also be chosen.
Conflicts (11 pairs): choosing one rules out the other. Works well with (55 pairs): natural combinations.

Key decisions first

Most other paths depend on these choices (many require or conflict with them).

Who pays: payer structure · 6 paths

Problem: Tens of millions of people have no coverage

Single public payer for everyoneChosen
- creates: Losing the choice of health plan and insurer competition (3 subpaths)
  - Hold the single payer to service standardsChosen
    - creates: Targets and quality metrics invite gaming (2 subpaths)
      Independent audits and few, simple measuresChosen
      Report measures publicly without tying pay to themRejected
  - Private supplemental plans for extrasChosen
    - creates: Copays keep billing systems alive and still deter poorer patients (3 subpaths)
      Automatic exemptions and annual collection through taxesChosen
      Drop point-of-care charges entirelyChosenrequires No cost sharing at the point of care
      Only flat, small charges on a few servicesRejected
  - Let people choose among public care organizationsChosenrequires Capitation for primary care and integrated systems
- creates: Replacing premiums with taxes (4 subpaths)
  - Payroll tax (employer and employee)Rejected
    - creates: Employer health taxes can lower wages at firms that never offered coverage (2 subpaths)
      Phase in employer taxes for small and low-wage firmsChosen
      No employer tax: fund from households directlyRejectedrequires Progressive income tax (including capital income)
  - Progressive income tax (including capital income)Rejected
  - Value-added taxRejected
  - A mix of payroll, income, and redirected spendingChosen
- creates: Central coverage decisions can feel like rationing (3 subpaths)
- creates: States lose control and budgets shift between levels of government (2 subpaths)
  - States administer under national rulesChosen
  - Maintenance-of-effort payments from statesChosen
Regulated multi-payer: everyone must have a non-profit or tightly regulated planRejectedrequires Automatic enrollment with free default coverage
- creates: Replacing premiums with taxes (4 subpaths)
  - Payroll tax (employer and employee)Rejected
    - creates: Employer health taxes can lower wages at firms that never offered coverage (2 subpaths)
      Phase in employer taxes for small and low-wage firmsChosen
      No employer tax: fund from households directlyRejectedrequires Progressive income tax (including capital income)
  - Progressive income tax (including capital income)Rejected
  - Value-added taxRejected
  - A mix of payroll, income, and redirected spendingChosen
- creates: Targets and quality metrics invite gaming (2 subpaths)
  - Independent audits and few, simple measuresChosen
  - Report measures publicly without tying pay to themRejected
Public option alongside private insuranceRejected
- creates: Two-tier care: a private fast lane for those who can pay (3 subpaths)
  - Allow private insurance for covered servicesRejected
  - Ban duplicate private insuranceRejected
  - Allow supplemental only (non-covered items)Chosen
Lower the Medicare age step by step (and enroll children at birth)Rejected
- creates: Replacing premiums with taxes (4 subpaths)
  - Payroll tax (employer and employee)Rejected
    - creates: Employer health taxes can lower wages at firms that never offered coverage (2 subpaths)
      Phase in employer taxes for small and low-wage firmsChosen
      No employer tax: fund from households directlyRejectedrequires Progressive income tax (including capital income)
  - Progressive income tax (including capital income)Rejected
  - Value-added taxRejected
  - A mix of payroll, income, and redirected spendingChosen
Automatic enrollment with free default coverageChosen
Individual mandate with larger subsidiesRejected

How providers are paid and prices set · 6 paths

Problem: U.S. prices are far higher than in other countries

All-payer rate settingChosen
- creates: Price limits can cause shortages, launch delays, or exits (3 subpaths)
Cap commercial prices at a multiple of MedicareChosen
- creates: Price limits can cause shortages, launch delays, or exits (3 subpaths)
Restore competition and leave prices to marketsRejected
Global budgets for hospitalsChosen
- creates: Fixed budgets can ration care (3 subpaths)
  - Budgets adjust automatically for population, age, and volumeChosen
  - Base budget plus activity paymentsChosenrequires Pay for activity on top of budgets
  - Waiting-time guarantees as a backstopChosenrequires Legal wait-time guarantees
- creates: Paying a fixed amount per patient rewards doing less (3 subpaths)
  - Risk adjustment plus outcome monitoringChosen
    - creates: Targets and quality metrics invite gaming (2 subpaths)
      Independent audits and few, simple measuresChosen
      Report measures publicly without tying pay to themRejected
  - Blended payment: part capitation, part fee-for-serviceChosen
  - Salaried clinicians in public or non-profit groupsRejected
Fee-for-service at public fee scheduleChosenrequires All-payer rate setting
Capitation for primary care and integrated systemsChosen
- creates: Paying a fixed amount per patient rewards doing less (3 subpaths)
- creates: Targets and quality metrics invite gaming (2 subpaths)
  - Independent audits and few, simple measuresChosen
  - Report measures publicly without tying pay to themRejected

What patients pay at the point of care · 3 paths

Problem: Underinsurance: covered, but can't afford to use it

No cost sharing at the point of careChosen
- creates: Replacing premiums with taxes (4 subpaths)
  - Payroll tax (employer and employee)Rejected
    - creates: Employer health taxes can lower wages at firms that never offered coverage (2 subpaths)
      Phase in employer taxes for small and low-wage firmsChosen
      No employer tax: fund from households directlyRejectedrequires Progressive income tax (including capital income)
  - Progressive income tax (including capital income)Rejected
  - Value-added taxRejected
  - A mix of payroll, income, and redirected spendingChosen
Modest copays with an income-based annual capRejected
- creates: Copays keep billing systems alive and still deter poorer patients (3 subpaths)
  - Automatic exemptions and annual collection through taxesChosen
  - Drop point-of-care charges entirelyChosenrequires No cost sharing at the point of care
  - Only flat, small charges on a few servicesRejected
Value-based cost sharingRejected
- creates: Copays keep billing systems alive and still deter poorer patients (3 subpaths)
  - Automatic exemptions and annual collection through taxesChosen
  - Drop point-of-care charges entirelyChosenrequires No cost sharing at the point of care
  - Only flat, small charges on a few servicesRejected

How the public share is financed · 4 paths

Problem: Replacing premiums with taxes

Payroll tax (employer and employee)Rejected
- creates: Employer health taxes can lower wages at firms that never offered coverage (2 subpaths)
  - Phase in employer taxes for small and low-wage firmsChosen
  - No employer tax: fund from households directlyRejectedrequires Progressive income tax (including capital income)
Progressive income tax (including capital income)Rejected
Value-added taxRejected
A mix of payroll, income, and redirected spendingChosen

How fast to transition · 3 paths

Problem: Transition disruption: jobs, companies, and familiar coverage

Phased transition in wavesChosen
Fast transition in one or two yearsRejected
State pilots firstRejected

All problems and their paths

Coverage & eligibility

Tens of millions of people have no coverage · 6 paths

Single public payer for everyoneChosen
- creates: Losing the choice of health plan and insurer competition (3 subpaths)
  - Hold the single payer to service standardsChosen
    - creates: Targets and quality metrics invite gaming (2 subpaths)
      Independent audits and few, simple measuresChosen
      Report measures publicly without tying pay to themRejected
  - Private supplemental plans for extrasChosen
    - creates: Copays keep billing systems alive and still deter poorer patients (3 subpaths)
      Automatic exemptions and annual collection through taxesChosen
      Drop point-of-care charges entirelyChosenrequires No cost sharing at the point of care
      Only flat, small charges on a few servicesRejected
  - Let people choose among public care organizationsChosenrequires Capitation for primary care and integrated systems
- creates: Replacing premiums with taxes (4 subpaths)
  - Payroll tax (employer and employee)Rejected
    - creates: Employer health taxes can lower wages at firms that never offered coverage (2 subpaths)
      Phase in employer taxes for small and low-wage firmsChosen
      No employer tax: fund from households directlyRejectedrequires Progressive income tax (including capital income)
  - Progressive income tax (including capital income)Rejected
  - Value-added taxRejected
  - A mix of payroll, income, and redirected spendingChosen
- creates: Central coverage decisions can feel like rationing (3 subpaths)
- creates: States lose control and budgets shift between levels of government (2 subpaths)
  - States administer under national rulesChosen
  - Maintenance-of-effort payments from statesChosen
Regulated multi-payer: everyone must have a non-profit or tightly regulated planRejectedrequires Automatic enrollment with free default coverage
- creates: Replacing premiums with taxes (4 subpaths)
  - Payroll tax (employer and employee)Rejected
    - creates: Employer health taxes can lower wages at firms that never offered coverage (2 subpaths)
      Phase in employer taxes for small and low-wage firmsChosen
      No employer tax: fund from households directlyRejectedrequires Progressive income tax (including capital income)
  - Progressive income tax (including capital income)Rejected
  - Value-added taxRejected
  - A mix of payroll, income, and redirected spendingChosen
- creates: Targets and quality metrics invite gaming (2 subpaths)
  - Independent audits and few, simple measuresChosen
  - Report measures publicly without tying pay to themRejected
Public option alongside private insuranceRejected
- creates: Two-tier care: a private fast lane for those who can pay (3 subpaths)
  - Allow private insurance for covered servicesRejected
  - Ban duplicate private insuranceRejected
  - Allow supplemental only (non-covered items)Chosen
Lower the Medicare age step by step (and enroll children at birth)Rejected
- creates: Replacing premiums with taxes (4 subpaths)
  - Payroll tax (employer and employee)Rejected
    - creates: Employer health taxes can lower wages at firms that never offered coverage (2 subpaths)
      Phase in employer taxes for small and low-wage firmsChosen
      No employer tax: fund from households directlyRejectedrequires Progressive income tax (including capital income)
  - Progressive income tax (including capital income)Rejected
  - Value-added taxRejected
  - A mix of payroll, income, and redirected spendingChosen
Automatic enrollment with free default coverageChosen
Individual mandate with larger subsidiesRejected

People lose coverage when their life changes (churn) · 2 paths

Job lock: people stay in jobs to keep insurance · 2 paths

Decouple coverage from employmentChosenrequires Single public payer for everyone
Keep employer insurance but make it portableRejected

Underinsurance: covered, but can't afford to use it · 3 paths

No cost sharing at the point of careChosen
- creates: Replacing premiums with taxes (4 subpaths)
  - Payroll tax (employer and employee)Rejected
    - creates: Employer health taxes can lower wages at firms that never offered coverage (2 subpaths)
      Phase in employer taxes for small and low-wage firmsChosen
      No employer tax: fund from households directlyRejectedrequires Progressive income tax (including capital income)
  - Progressive income tax (including capital income)Rejected
  - Value-added taxRejected
  - A mix of payroll, income, and redirected spendingChosen
Modest copays with an income-based annual capRejected
- creates: Copays keep billing systems alive and still deter poorer patients (3 subpaths)
  - Automatic exemptions and annual collection through taxesChosen
  - Drop point-of-care charges entirelyChosenrequires No cost sharing at the point of care
  - Only flat, small charges on a few servicesRejected
Value-based cost sharingRejected
- creates: Copays keep billing systems alive and still deter poorer patients (3 subpaths)
  - Automatic exemptions and annual collection through taxesChosen
  - Drop point-of-care charges entirelyChosenrequires No cost sharing at the point of care
  - Only flat, small charges on a few servicesRejected

Narrow networks and out-of-network surprises · 2 paths

Immigrants and mixed-status families fall through gaps · 2 paths

Cover all residents regardless of immigration statusChosen
- creates: Covering all residents raises cost and migration concerns (2 subpaths)
  - Residence period before eligibilityChosen
  - Cover from day oneRejected
Cover lawful residents; keep emergency care for othersRejected

U.S. territories get capped, lower federal health funding · 3 paths

Affordability & medical debt

Medical debt affects about 100 million people · 3 paths

Premiums are a large, flat, hidden tax on wages · 2 paths

Replace premiums with progressive taxesChosenrequires Single public payer for everyone
- creates: Replacing premiums with taxes (4 subpaths)
  - Payroll tax (employer and employee)Rejected
    - creates: Employer health taxes can lower wages at firms that never offered coverage (2 subpaths)
      Phase in employer taxes for small and low-wage firmsChosen
      No employer tax: fund from households directlyRejectedrequires Progressive income tax (including capital income)
  - Progressive income tax (including capital income)Rejected
  - Value-added taxRejected
  - A mix of payroll, income, and redirected spendingChosen
Income-based premiums in a multi-payer systemRejectedrequires Regulated multi-payer: everyone must have a non-profit or tightly regulated plan
- creates: Employer health taxes can lower wages at firms that never offered coverage (2 subpaths)
  - Phase in employer taxes for small and low-wage firmsChosen
  - No employer tax: fund from households directlyRejectedrequires Progressive income tax (including capital income)

Patients can't know prices in advance · 2 paths

One public price list for every serviceChosenrequires All-payer rate setting
Enforce price transparency rulesChosen

Surprise billing and a runaway arbitration system · 2 paths

Set a default out-of-network rate instead of arbitrationChosen
Eliminate out-of-network statusChosenrequires Every licensed provider is in-network

Insurer practices

Claim denials · 2 paths

Regulate denials: reporting, penalties, and fast independent appealsChosen
Public coverage rules with clinician-led reviewChosenrequires Single public payer for everyone
- creates: Central coverage decisions can feel like rationing (3 subpaths)

Prior authorization delays and blocks care · 2 paths

Medicare Advantage overpayments and coding intensity · 2 paths

Fold Medicare Advantage into the public programChosenrequires Single public payer for everyone
- creates: Losing the choice of health plan and insurer competition (3 subpaths)
  - Hold the single payer to service standardsChosen
    - creates: Targets and quality metrics invite gaming (2 subpaths)
      Independent audits and few, simple measuresChosen
      Report measures publicly without tying pay to themRejected
  - Private supplemental plans for extrasChosen
    - creates: Copays keep billing systems alive and still deter poorer patients (3 subpaths)
      Automatic exemptions and annual collection through taxesChosen
      Drop point-of-care charges entirelyChosenrequires No cost sharing at the point of care
      Only flat, small charges on a few servicesRejected
  - Let people choose among public care organizationsChosenrequires Capitation for primary care and integrated systems
Fix Medicare Advantage paymentsChosen
- creates: Targets and quality metrics invite gaming (2 subpaths)
  - Independent audits and few, simple measuresChosen
  - Report measures publicly without tying pay to themRejected

Insurer overhead and profit · 2 paths

Pharmacy benefit managers profit from opaque drug pricing · 2 paths

Prices & market power

U.S. prices are far higher than in other countries · 6 paths

All-payer rate settingChosen
- creates: Price limits can cause shortages, launch delays, or exits (3 subpaths)
Cap commercial prices at a multiple of MedicareChosen
- creates: Price limits can cause shortages, launch delays, or exits (3 subpaths)
Restore competition and leave prices to marketsRejected
Global budgets for hospitalsChosen
- creates: Fixed budgets can ration care (3 subpaths)
  - Budgets adjust automatically for population, age, and volumeChosen
  - Base budget plus activity paymentsChosenrequires Pay for activity on top of budgets
  - Waiting-time guarantees as a backstopChosenrequires Legal wait-time guarantees
- creates: Paying a fixed amount per patient rewards doing less (3 subpaths)
  - Risk adjustment plus outcome monitoringChosen
    - creates: Targets and quality metrics invite gaming (2 subpaths)
      Independent audits and few, simple measuresChosen
      Report measures publicly without tying pay to themRejected
  - Blended payment: part capitation, part fee-for-serviceChosen
  - Salaried clinicians in public or non-profit groupsRejected
Fee-for-service at public fee scheduleChosenrequires All-payer rate setting
Capitation for primary care and integrated systemsChosen
- creates: Paying a fixed amount per patient rewards doing less (3 subpaths)
- creates: Targets and quality metrics invite gaming (2 subpaths)
  - Independent audits and few, simple measuresChosen
  - Report measures publicly without tying pay to themRejected

Hospital and physician consolidation raises prices · 2 paths

Stronger antitrust: block mergers and undo someChosen
Make consolidation irrelevant to priceChosenrequires All-payer rate setting

Private equity roll-ups in medicine · 2 paths

Facility fees: the same service costs more in a hospital-owned building · 2 paths

Site-neutral paymentChosen
Ban facility fees for off-campus clinicsRejected

Executive pay and nonprofit status · 2 paths

Tie nonprofit tax exemption to community benefitChosen
Public review of hospital budgetsChosenrequires Global budgets for hospitals

Drugs, patents & supply chain

Brand-name drug prices far above production cost · 3 paths

National negotiation for all drugsChosen
- creates: Price limits can cause shortages, launch delays, or exits (3 subpaths)
- creates: Central coverage decisions can feel like rationing (3 subpaths)
International reference pricingRejected
- creates: Price limits can cause shortages, launch delays, or exits (3 subpaths)
Public manufacturing of off-patent drugsChosen

Patent thickets and evergreening delay generics · 3 paths

Limit patent thickets and evergreeningChosen
Use government march-in and compulsory licensingRejected
Keep the current patent systemRejected

R&D is funded by high prices, which ties innovation to unaffordability · 3 paths

Expand public R&D fundingChosen
- creates: Government chooses which research gets funded (2 subpaths)
  - Independent peer review with set-asides for high-risk ideasChosen
  - Keep private R&D for most drugs; public funds fill gapsRejected
Prize funds and advance market commitmentsChosen
- creates: Government chooses which research gets funded (2 subpaths)
  - Independent peer review with set-asides for high-risk ideasChosen
  - Keep private R&D for most drugs; public funds fill gapsRejected
Value-based prices that reward real innovationChosen
- creates: Central coverage decisions can feel like rationing (3 subpaths)

Drug shortages of cheap, essential generics · 2 paths

Pay more for reliable supplyChosen
National stockpile and onshore productionChosen

Pharmacy closures and pharmacy deserts · 2 paths

Geography & physical access

Rural hospital closures · 2 paths

Global budgets for rural hospitalsChosenrequires Global budgets for hospitals
- creates: Fixed budgets can ration care (3 subpaths)
  - Budgets adjust automatically for population, age, and volumeChosen
  - Base budget plus activity paymentsChosenrequires Pay for activity on top of budgets
  - Waiting-time guarantees as a backstopChosenrequires Legal wait-time guarantees
Convert to emergency and outpatient centersChosen

Maternity care deserts · 2 paths

Standby payments to keep labor units openChosen
Expand midwives and birth centersChosen
- creates: Quality concerns when non-physicians practice independently (2 subpaths)
  - Measure outcomes by clinician type and adjust scopeChosen
  - Supervised transition period before independenceChosen

Health professional shortage areas · 3 paths

Loan forgiveness and service obligationsChosen
Higher pay in shortage areasChosen
Permanent telehealth coverageChosen

Getting to care: transportation and ambulances · 2 paths

Cover ambulance and non-emergency transportChosen
Publicly funded EMS as essential serviceChosenrequires Global budgets for hospitals

Workforce

Physician shortage, especially in primary care · 3 paths

Medical education debt shapes specialty choice · 2 paths

Nursing and direct-care shortages and burnout · 2 paths

Minimum nurse staffing ratiosChosen
- creates: Staffing mandates raise costs and may close facilities (2 subpaths)
  - Phase mandates in with workforce growth, funded in ratesChosen
  - Hardship waivers for shortage areasChosen
Expand nursing schools and faculty payChosen

Clinician burnout from paperwork and EHR work · 2 paths

Cut documentation and billing burdenChosenrequires Single public payer for everyone
Fund scribes and AI documentationChosen

Scope-of-practice limits waste capacity · 2 paths

Full practice authority for NPs, PAs, pharmacists, dental therapistsChosen
- creates: Quality concerns when non-physicians practice independently (2 subpaths)
  - Measure outcomes by clinician type and adjust scopeChosen
  - Supervised transition period before independenceChosen
Team-based care with physician oversightRejected

Quality, safety & outcomes

Worse outcomes than peer countries despite the highest spending · 2 paths

Shift spending toward primary careChosen
Invest outside health careChosen

High maternal mortality and postpartum coverage gaps · 2 paths

Medical errors and poor care coordination · 2 paths

Racial, income, and geographic disparities · 2 paths

Equity-adjusted fundingChosen
Rely on universal coverage and uniform ratesChosenrequires All-payer rate setting

Malpractice system: slow, costly, and drives defensive medicine · 2 paths

No-fault compensation for medical injuryChosen
Safe harbor for following clinical guidelinesRejected

Administration & complexity

About $1 trillion a year in administrative cost · 2 paths

One claims system and standard rulesChosenrequires Single public payer for everyone
Standardize across many payersChosen

Simplifying billing would displace hundreds of thousands of workers · 2 paths

Worker transition programChosen
Redeploy billing staff to care coordinationChosen

Waste, fraud & low-value care

Low-value care and overtreatment · 2 paths

Evidence-based coverage decisionsChosen
- creates: Central coverage decisions can feel like rationing (3 subpaths)
Feedback and clinician nudgesChosen

Fraud and improper payments · 2 paths

Pre-payment analytics and auditsChosen
Stricter provider enrollmentChosen

Mental health & substance use

Mental health care is hard to get · 2 paths

Pay mental health clinicians at parityChosen
Stepped care and integration into primary careChosen
- creates: Targets and quality metrics invite gaming (2 subpaths)
  - Independent audits and few, simple measuresChosen
  - Report measures publicly without tying pay to themRejected

Overdose crisis and gaps in addiction treatment · 2 paths

Easy access to medication treatmentChosen
Harm reduction servicesChosen

Long-term & end-of-life care

Long-term care requires spending down to poverty · 3 paths

Universal long-term care insuranceChosen
- creates: Covering long-term care can pull unpaid family care into the paid system (2 subpaths)
  - Standardized needs assessment and tiered benefitsChosen
  - Cash benefit option for family caregiversChosen
- creates: Replacing premiums with taxes (4 subpaths)
  - Payroll tax (employer and employee)Rejected
    - creates: Employer health taxes can lower wages at firms that never offered coverage (2 subpaths)
      Phase in employer taxes for small and low-wage firmsChosen
      No employer tax: fund from households directlyRejectedrequires Progressive income tax (including capital income)
  - Progressive income tax (including capital income)Rejected
  - Value-added taxRejected
  - A mix of payroll, income, and redirected spendingChosen
Keep means testing, but expand home careChosen
Catastrophic coverage after a waiting periodRejected

Nursing home understaffing and quality · 2 paths

Minimum staffing and financial transparencyChosen
- creates: Staffing mandates raise costs and may close facilities (2 subpaths)
  - Phase mandates in with workforce growth, funded in ratesChosen
  - Hardship waivers for shortage areasChosen
Shift to small homes and home careChosen

Hospice growth, for-profit entry, and fraud · 2 paths

Tighter hospice oversightChosen
Require non-profit hospiceRejected

Dental, vision & hearing

Dental, vision, and hearing are mostly uncovered · 2 paths

Cover dental, vision, and hearing fullyChosen
Cover preventive and basic dental; hearing aids and glasses with limitsRejected
- creates: Copays keep billing systems alive and still deter poorer patients (3 subpaths)
  - Automatic exemptions and annual collection through taxesChosen
  - Drop point-of-care charges entirelyChosenrequires No cost sharing at the point of care
  - Only flat, small charges on a few servicesRejected

Public health & prevention

Prevention and public health are underfunded · 2 paths

Dedicated public health fundingChosen
Free preventive care and vaccinesChosen

Housing, food, and transportation drive health, but health care isn't designed for them · 2 paths

Let health budgets pay for housing and foodChosen
Keep social programs separateRejected

Data, technology & privacy

Records don't follow patients · 2 paths

National health record and patient IDChosen
Mandatory data-sharing standardsChosen

Cyberattacks can halt payments and care · 2 paths

Health privacy · 2 paths

Strong health privacy lawChosen
Opt-out of national record sharingChosen

Risks a universal system can create

Longer waits if demand grows faster than capacity · 3 paths

Legal wait-time guaranteesChosen
- creates: Targets and quality metrics invite gaming (2 subpaths)
  - Independent audits and few, simple measuresChosen
  - Report measures publicly without tying pay to themRejected
Build capacity before demand risesChosen
Pay for activity on top of budgetsChosen

Two-tier care: a private fast lane for those who can pay · 3 paths

Allow private insurance for covered servicesRejected
Ban duplicate private insuranceRejected
Allow supplemental only (non-covered items)Chosen

Chronic underfunding by government budgets · 3 paths

Dedicated trust fund with automatic indexingChosen
- creates: Replacing premiums with taxes (4 subpaths)
  - Payroll tax (employer and employee)Rejected
    - creates: Employer health taxes can lower wages at firms that never offered coverage (2 subpaths)
      Phase in employer taxes for small and low-wage firmsChosen
      No employer tax: fund from households directlyRejectedrequires Progressive income tax (including capital income)
  - Progressive income tax (including capital income)Rejected
  - Value-added taxRejected
  - A mix of payroll, income, and redirected spendingChosen
Annual appropriations from general revenueRejected
- creates: Fixed budgets can ration care (3 subpaths)
  - Budgets adjust automatically for population, age, and volumeChosen
  - Base budget plus activity paymentsChosenrequires Pay for activity on top of budgets
  - Waiting-time guarantees as a backstopChosenrequires Legal wait-time guarantees
Spending-growth target tied to GDP, reviewed publiclyChosen

Under-investment in equipment and facilities · 2 paths

Separate public capital budget, planned regionallyChosen
- creates: Fixed budgets can ration care (3 subpaths)
  - Budgets adjust automatically for population, age, and volumeChosen
  - Base budget plus activity paymentsChosenrequires Pay for activity on top of budgets
  - Waiting-time guarantees as a backstopChosenrequires Legal wait-time guarantees
Build a capital allowance into ratesRejected

Slower access to new drugs and technology · 3 paths

Cover new treatments at launch, then reassessChosen
Recycle part of drug savings into researchChosenrequires Expand public R&D funding
- creates: Government chooses which research gets funded (2 subpaths)
  - Independent peer review with set-asides for high-risk ideasChosen
  - Keep private R&D for most drugs; public funds fill gapsRejected
Accept somewhat slower adoptionRejected
- creates: Central coverage decisions can feel like rationing (3 subpaths)

Providers leave, retire, or go cash-only if pay drops · 3 paths

Phase rate changes in over several yearsChosen
Strict opt-out rules for cash-only practiceChosen
Lower costs for clinicians, not only payChosenrequires One claims system and standard rules

Transition disruption: jobs, companies, and familiar coverage · 3 paths

Phased transition in wavesChosen
Fast transition in one or two yearsRejected
State pilots firstRejected

One payer becomes one target · 2 paths

Fixed budget share for program integrityChosen
Regional administrators under national rulesChosen
- creates: Targets and quality metrics invite gaming (2 subpaths)
  - Independent audits and few, simple measuresChosen
  - Report measures publicly without tying pay to themRejected

Problems created by solution paths

Losing the choice of health plan and insurer competition · 3 paths

Hold the single payer to service standardsChosen
- creates: Targets and quality metrics invite gaming (2 subpaths)
  - Independent audits and few, simple measuresChosen
  - Report measures publicly without tying pay to themRejected
Private supplemental plans for extrasChosen
- creates: Copays keep billing systems alive and still deter poorer patients (3 subpaths)
  - Automatic exemptions and annual collection through taxesChosen
  - Drop point-of-care charges entirelyChosenrequires No cost sharing at the point of care
  - Only flat, small charges on a few servicesRejected
Let people choose among public care organizationsChosenrequires Capitation for primary care and integrated systems

Replacing premiums with taxes · 4 paths

Payroll tax (employer and employee)Rejected
- creates: Employer health taxes can lower wages at firms that never offered coverage (2 subpaths)
  - Phase in employer taxes for small and low-wage firmsChosen
  - No employer tax: fund from households directlyRejectedrequires Progressive income tax (including capital income)
Progressive income tax (including capital income)Rejected
Value-added taxRejected
A mix of payroll, income, and redirected spendingChosen

Employer health taxes can lower wages at firms that never offered coverage · 2 paths

Copays keep billing systems alive and still deter poorer patients · 3 paths

Automatic exemptions and annual collection through taxesChosen
Drop point-of-care charges entirelyChosenrequires No cost sharing at the point of care
Only flat, small charges on a few servicesRejected

Central coverage decisions can feel like rationing · 3 paths

Fixed budgets can ration care · 3 paths

Budgets adjust automatically for population, age, and volumeChosen
Base budget plus activity paymentsChosenrequires Pay for activity on top of budgets
Waiting-time guarantees as a backstopChosenrequires Legal wait-time guarantees

Paying a fixed amount per patient rewards doing less · 3 paths

Risk adjustment plus outcome monitoringChosen
- creates: Targets and quality metrics invite gaming (2 subpaths)
  - Independent audits and few, simple measuresChosen
  - Report measures publicly without tying pay to themRejected
Blended payment: part capitation, part fee-for-serviceChosen
Salaried clinicians in public or non-profit groupsRejected

Price limits can cause shortages, launch delays, or exits · 3 paths

Government chooses which research gets funded · 2 paths

Quality concerns when non-physicians practice independently · 2 paths

Staffing mandates raise costs and may close facilities · 2 paths

Covering long-term care can pull unpaid family care into the paid system · 2 paths

Covering all residents raises cost and migration concerns · 2 paths

Residence period before eligibilityChosen
Cover from day oneRejected

Targets and quality metrics invite gaming · 2 paths

States lose control and budgets shift between levels of government · 2 paths

Common trade-offs

Raises spending or loosens control over it · 0 paths

Takes years, or money up front, before it pays off · 0 paths

Requires difficult enforcement · 0 paths

Depends on other changes to work · 0 paths

Solves only part of the problem · 0 paths

Concentrates costly patients in some plans · 0 paths

Directs benefits or burdens imperfectly · 0 paths

Faces political, industry, or legal opposition · 0 paths

Reduces income or business for affected groups · 0 paths

Limits choice or applies one rule to every setting · 0 paths

Requires new or changing information systems · 0 paths

Depends on uncertain evidence or judgments · 0 paths

Leaves less complete or useful data · 0 paths

Requires workers to change roles or skills · 0 paths

Leaves funding vulnerable or inflexible · 0 paths

Limits compensation for people who are harmed · 0 paths

Leaves unequal burdens on family caregivers · 0 paths

Adds paperwork, coordination, or complexity · 0 paths

Makes performance and quality hard to oversee · 0 paths

Weakens incentives for desired behavior · 0 paths