The Implementation Appendices
The history, the law, the mechanisms and the numbers behind the plan, one topic per appendix
The plan is written to be read on its own: what we will do, in what order, and why. These appendices hold the background a reader needs to judge it. Each one stands alone as an explanation of a single subject, from the program that built most of the country's hospitals to the Senate rule that decides what can pass. Read the ones you want, in any order.
A. The Hill-Burton Act and the American tradition of building health care
In 1946 the federal government began surveying every county for hospital shortages and paying to build where the shortages were. Over three decades it built or modernized 6,800 facilities, and it is the reason most mid-century American towns got a hospital at all. This appendix tells how the program worked, what it got wrong, why it was allowed to lapse, and what the plan's capital program copies and corrects.
B. How America trains, licenses, and limits its doctors and nurses
The doctor shortage is not a natural condition. It is the product of a residency cap written into a 1997 budget law, a private accreditor no government can overrule, a visa rule that sends trained physicians home, and 70 state licenses that stop at the state line. Nursing has a different bottleneck: schools turn away tens of thousands of qualified applicants for want of faculty and clinical placements. This appendix explains each constraint and the fix aimed at it.
C. How Medicare sets prices today, and how Japan and Maryland do it
Every medical service in the country carries a score, and the scores are recommended by a committee of the American Medical Association that surveys its own members. The government adopts nine in ten of its recommendations because it has no data of its own. This appendix explains that machinery, why the schedule has never been rebuilt, how Japan reprices its entire schedule every two years from a public survey, and how Maryland has paid its hospitals by global budget for a decade.
D. How other countries decide what is covered and how long you wait
Every health system rations. The difference is who draws the line and whether anyone can see it. This appendix describes the public bodies the plan's benefits schedule is modeled on, in England, Germany, and Japan, the waiting-time guarantees of England and Denmark, the standard way waits are measured, and the Australian settlement in which a universal system coexists with the right to pay to be seen sooner.
E. Drug patents, Section 1498, biologics, and public manufacturing
Since 1910 the federal government has had the power to use any patent without permission, paying the holder afterward. It used that power to buy drugs routinely through the 1960s and cut Bayer's price for ciprofloxacin nearly in half in 2001 merely by mentioning it. This appendix explains the authority, the court rulings that keep it from reaching Medicare, the separate 12-year lock on biologics, what using it costs, and the public and non-profit manufacturers that show a factory can be built.
F. Pharmacy benefit managers and the pharmacy payment system
Three companies, all owned by insurers, handle most American prescriptions, and the sub-second transaction at every pharmacy counter runs on systems they own. This appendix explains what a pharmacy benefit manager does and how it profits, why the payment plumbing cannot be switched off on a Tuesday, how the 2006 launch of Medicare Part D failed at exactly this point, and the sequence by which the plan takes the system over rather than replacing it.
G. What the insurance industry has become, and what the law allows us to do about it
UnitedHealth employs or contracts one in ten American doctors, and insurance is now the smaller half of its business. This appendix maps the conglomerates, explains how an insurance business is wound down and why no compensation is owed for a market Congress has closed, describes Medicare Advantage and its overpayment, and tells why Trade Adjustment Assistance failed the workers it promised to help, so that the plan's transition guarantee does not.
H. Hospital ownership around the world, and the legal ladder for the takeover cases
South Korea and Japan run two of the best health systems on earth with private hospitals, under one condition America has never imposed: the hospital may not pay out profits. This appendix sets out the comparative evidence that ownership form is not what America gets wrong, what the countries that work do instead, and the four legal routes, from state charitable-trust law to eminent domain, for the operators who forfeit the benefit of the doubt.
I. The health systems the federal government already runs
The federal government already provides or pays for care for 25 million people outside Medicare and Medicaid, at levels of generosity from $13,473 a head to $4,078 for the care it owes by treaty to Native Americans. This appendix describes the VA, the Indian Health Service, the military and federal-employee plans, the capped Medicaid of the territories, and the 1965 rule that cuts off coverage at the jailhouse door, and what the plan changes in each.
J. The full cost table, its assumptions, the one-off costs, and the unpriced liability
The plan costs roughly what America already pays. This appendix shows the arithmetic line by line: what each savings figure assumes, why the operating cost of new capacity is the largest single item, how induced use is budgeted, the medical debt refund costed three ways, and the contract damages the Treasury owes when a statute breaks the government's own agreements.
K. The evidence behind the transition design
Every rule in the plan's transition is written against a specific disaster. This appendix describes them: the Oregon lottery that measured what free coverage does to demand, the Medicaid unwinding that removed 25 million people mostly for paperwork, the Part D launch that left patients at the counter without their drugs, the Canadian payroll system that failed when the experienced staff were cut in the same year, and the run-out problem hidden inside employer insurance.
L. The National Prior Authorization Service and the end of paperwork
In American health care the delay and the paperwork are not a malfunction. They are how the system makes money. This appendix sets out the full design of the portal through which every prior-authorization request in America would flow, why its penalties are computed rather than adjudicated, the consumer tools that are quietly the plumbing of a single payer, and the ways the design goes wrong if the statute is careless.
M. Why the filibuster has to go
The plan assumes the Senate filibuster is gone, and this appendix explains why nothing else works: what budget reconciliation can carry, what the Byrd rule strikes, the precedents from the Affordable Care Act repeal fight and the Inflation Reduction Act's two insulin caps, and why the 60-vote path the ACA used in 2009 will not exist again.
Interactive data · 160 countries
Where the U.S. Ranks in Health↗
Four rankings built from live World Bank, WHO and OECD data: the healthiest countries, the most efficient systems, who owns the hospitals, and who pays. The United States is not in the top ten of any of them.
Explore the rankings →