Universal HealthcareBy NextBestFit
Part 2

Changes by phase

Every change to the system, grouped into phases. Each change has its tasks, design choices and alternatives, costs with calculations, trade-offs, risks, the existing laws and institutions it affects, and comparisons with other countries. Political feasibility is deliberately set aside.

Draft
The steps below are the detailed build-out of the plan. The full list of concrete changes from every chosen solution path is on Changes by phase. The picks are drafts awaiting review in the review ledger.

Phase 0: Preparation

Before coverage starts

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.

  1. 0.1Set each state's contribution4 tasks · 2 cost items

Phase 1: Enactment & build

Year 0: the 18 months between signing and first coverage

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

  1. 1.1Create the Universal Health Administration7 tasks · 3 cost items
  2. 1.2Create the UHP Trust Fund4 tasks · 16 cost items
  3. 1.3Build the claims, payment & data systems8 tasks · 1 cost items
  4. 1.4Enroll everyone automatically7 tasks · 1 cost items
  5. 1.5Define the benefit package & cost sharing7 tasks · 2 cost items
  6. 1.6Sign up providers & set participation rules6 tasks · 0 cost items
  7. 1.7Set the national fee schedule6 tasks · 3 cost items
  8. 1.8Set hospital global budgets7 tasks · 2 cost items
  9. 1.9Create the national formulary & negotiate drug prices7 tasks · 3 cost items
  10. 1.10Create the Health Technology Assessment Institute4 tasks · 0 cost items
  11. 1.11Rewrite insurance & benefits law6 tasks · 0 cost items
  12. 1.12Set up the new taxes6 tasks · 15 cost items
  13. 1.13Launch the displaced-worker program5 tasks · 4 cost items
  14. 1.14Set data governance & privacy rules4 tasks · 0 cost items

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

Year 1

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

  1. 2.1Upgrade Medicare enrollees into UHP7 tasks · 1 cost items
  2. 2.2Enroll children and adults 55–645 tasks · 0 cost items
  3. 2.3Enforce maintenance of compensation5 tasks · 1 cost items
  4. 2.4Run the Hospital Transition Fund4 tasks · 1 cost items
  5. 2.5Launch the wait-time guarantee5 tasks · 1 cost items
  6. 2.6Expand capacity before demand peaks8 tasks · 5 cost items
  7. 2.7Launch dental, vision & hearing benefits4 tasks · 2 cost items

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

Years 2–3

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

  1. 3.1Enroll adults 45–54 (Year 2) and 35–44 (Year 3)4 tasks · 0 cost items
  2. 3.2Make home- and community-based care an entitlement5 tasks · 3 cost items
  3. 3.3Wind down the private health insurers6 tasks · 8 cost items
  4. 3.4Converge provider rates3 tasks · 0 cost items
  5. 3.5Close the ACA Marketplaces3 tasks · 2 cost items
  6. 3.6Create integrated care organizations (ICOs)4 tasks · 1 cost items

Phase 4: Wave 4: everyone

Year 4

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

  1. 4.1Enroll everyone remaining2 tasks · 0 cost items
  2. 4.2End employer-sponsored insurance for covered services6 tasks · 11 cost items
  3. 4.3Fold Medicaid and CHIP into UHP6 tasks · 5 cost items
  4. 4.4Coordinate with continuing payers: workers' comp, auto, VA, TRICARE, IHS6 tasks · 3 cost items
  5. 4.5Switch every tax to its full rate3 tasks · 1 cost items

Phase 5: Stabilize & govern

Year 5 onward

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.

  1. 5.1Set a spending growth target3 tasks · 0 cost items
  2. 5.2Run program integrity & fraud control4 tasks · 0 cost items
  3. 5.3Run an independent evaluation and the Year-10 review3 tasks · 0 cost items
  4. 5.4Pilot a no-fault patient compensation system (optional)3 tasks · 0 cost items
  5. 5.5Plan capacity regionally3 tasks · 1 cost items