By NextBestFitWaves 2 & 3: working-age adults
Bring adults 35–54 into UHP, convert long-term care into an entitlement, and wind down the private insurance industry in an orderly way.
- Adults 35+ enrolled with no measurable coverage gap.
- HCBS waiting lists eliminated.
- Every health insurer has an approved run-off plan.
- Rates for all providers at least 50% converged to UHP levels.
Changes from chosen paths in this phase: 11
8 chosen solution paths (draft picks awaiting review) land in this phase. See every change.
- Public review of hospital budgets
- Publicly funded EMS as essential service
- Pay for activity on top of budgets
- Phase rate changes in over several years
- Let people choose among public care organizations
- Budgets adjust automatically for population, age, and volume
- Base budget plus activity payments
- Risk adjustment plus outcome monitoring
Detailed steps
- 3.1Enroll adults 45–54 (Year 2) and 35–44 (Year 3)
About 85 million working-age adults move from employer, Marketplace, Medicaid, or no coverage into UHP. Employer plans shrink to covering only workers under 35 and their spouses.
4 tasks · 0 cost items · Start of Years 2 and 3 - 3.2Make home- and community-based care an entitlement
Long-term services at home stop depending on Medicaid's poverty rules and capped waivers. HCBS spending goes from $320.5B to $353.5B, home health from $169.4B to $204.5B, and nursing facilities from $219.9B to $225.7B.
5 tasks · 3 cost items · Year 2 - 3.3Wind down the private health insurers
Insurers' UHP-duplicative business ends. They must process all claims for prior coverage (run-off), protect policyholders, and convert or close in an orderly way. The 'Net cost of insurance' line falls from $306.0B to $26.4B.
6 tasks · 8 cost items · Years 1–5 - 3.4Converge provider rates
Each provider's payments move from its prior blended rate toward UHP rates by 25% a year over four years, so revenue changes are gradual.
3 tasks · 0 cost items · Years 1–4 - 3.5Close the ACA Marketplaces
HealthCare.gov and state exchanges close at the end of Year 3. The $116.6B in premium tax credits is redirected to the UHP Trust Fund.
3 tasks · 2 cost items · End of Year 3 - 3.6Create integrated care organizations (ICOs)
Provider-run integrated systems can accept a single risk-adjusted global budget for patients who choose them. This preserves the Kaiser/Geisinger model without an insurance layer.
4 tasks · 1 cost items · Years 2–4