Appendix D: How other countries decide what is covered and how long you wait

This appendix supports the section "What's covered, and what happens if you have to wait" in the plan. It describes the institutions the plan's benefits schedule and waiting-time guarantee are modeled on.

Every system rations. The question is how, and by whom.

No health system pays for everything. Every one of them draws a line between what the public purse covers and what it does not, and the difference between systems is where the line is drawn, who draws it, and whether anyone can see it.

The United States draws the line more harshly than any other rich country and less visibly. It rations by price, by deductible, by network, by prior authorization, and by claim denial. The decision in each case is made by an employee of a company whose profit rises when the answer is no, under criteria that are proprietary, with no published reasoning, and with an appeals process most people cannot afford to use. Nobody in the American system is told "the public does not cover this." They are told "your plan does not cover this," and the plan does not have to say why.

The countries the plan borrows from do the same job with a public body, a published method, and a right of appeal.

England: NICE

The National Institute for Health and Care Excellence was created in 1999 to answer a question the National Health Service had been avoiding: which new drugs and treatments should it pay for, and how should it decide? NICE evaluates a treatment's clinical effectiveness and its cost against the health it produces, measured in quality-adjusted life years, and it recommends for or against NHS funding. Its working threshold has for two decades been on the order of £20,000 to £30,000 per quality-adjusted life year, with higher thresholds for end-of-life treatments and, more recently, for the rarest diseases. The threshold is public. The evidence reviews are public. The committee meetings are public. Manufacturers, patient groups, and clinicians submit evidence and comment on draft decisions before they are final, and a decision can be appealed.

What NICE changed was not the amount of rationing but its character. Before NICE, whether a patient got a new cancer drug depended on the budget of their local health authority, which the press called the postcode lottery. After NICE, a treatment it recommends must be funded everywhere in England within three months, and a treatment it rejects is rejected for a reason anyone can read. NICE is attacked from both sides, by manufacturers for saying no and by patients for saying no, and that is the sign of a body doing its job in the open.

Germany: IQWiG and the Federal Joint Committee

Germany's system has two layers. The Institute for Quality and Efficiency in Health Care, IQWiG, was created in 2004 as an independent scientific institute that assesses the evidence for drugs and treatments, and in particular whether a new drug offers any added benefit over the existing standard of care. The decision itself is made by the Federal Joint Committee, a self-governing body of the sickness funds, the physicians, and the hospitals, with patient representatives who take part but do not vote. Since 2011 every new drug in Germany has faced an added-benefit assessment within its first year on the market, and the price the funds pay is negotiated on the basis of that assessment. A drug with no demonstrated added benefit is paid at the price of the drug it did not improve on.

The German model shows something the plan relies on: that the scientific assessment and the coverage decision can be separated, with the science done by an independent institute and the decision made by a body representing the payers and the providers, in public, under a published method.

Japan: Chuikyo

Japan's Central Social Insurance Medical Council, the body that reprices the entire fee schedule every two years, is described in Appendix C. It also decides what the schedule includes. A treatment not on the schedule is not covered by Japanese insurance, and a physician who provides an unlisted treatment alongside covered care generally forfeits the insurance payment for the whole episode, which is the strongest form of the rule that a provider may not blend public and private billing for the same care. The list is revised on the same two-year cycle as the prices, in public, by the same council of payers, providers, and public-interest members.

What the plan builds

The plan creates an expert body that decides what the national program pays for, meets in public, publishes its reasoning and its cost-effectiveness thresholds, takes comment before deciding, and seats tribal representation as a treaty matter. It starts from inclusion: everything medically established is covered, and the body's job is to exclude what does not work, not to ration what does. A treating physician can override the schedule for an individual patient whose circumstances require it, because the schedule governs the general case and the doctor governs the specific one. And what the schedule does not cover, anyone may buy.

Waiting-time guarantees

A published benefits schedule answers what is covered. It does not answer when. A covered service that takes nine months to get is rationed by delay, and delay is the mechanism by which single-payer systems are most often, and often fairly, criticized. The plan's answer is a guarantee, borrowed from two systems that have run one for years.

England's 18 weeks. Since 2008 the NHS in England has operated a standard that a patient referred by a general practitioner for non-urgent hospital treatment should start that treatment within 18 weeks, and the standard was written into the NHS Constitution as a right. Urgent cases have shorter clocks: suspected cancer is to be seen within two weeks of referral. Performance against the standard is measured for every hospital and published monthly. The standard has been missed for most of the last decade, which is itself instructive: the guarantee did not create the capacity to meet it, and a target without the workforce and beds behind it becomes a monthly record of failure. That is the reason the plan's guarantee is paired with a capital program and a workforce program rather than standing alone, and the reason the rule against selling faster access is phased in as each sector meets its deadline rather than on day one.

Denmark's 30 days. Denmark took a different approach. Since 2007 a patient who cannot be treated within one month in the public system has the right to be treated at a private hospital or abroad, at the public system's expense. The guarantee has teeth because it moves money: a region that cannot treat a patient in time pays someone else to. The plan copies this directly. When no local facility can provide a covered service before the published deadline, the patient is automatically entitled to treatment at any other participating facility in the country at public expense, paid from a national pool funded separately from any hospital's own budget, so that the hospital that missed the deadline is not also the one deciding whether to honor the guarantee.

Different clocks for different needs. The plan sets a maximum wait for every service with independent experts, on the pattern of both systems: days for urgent cases, weeks for routine ones, and a published number for each.

Measuring the wait: the third next available appointment

A guarantee has to be measured, and how it is measured decides whether it can be gamed. The plan uses the standard measure that schedulers and health systems already use, the number of days until the third open appointment on a clinic's calendar for a given service.

The reason it is the third and not the first is simple. The first open slot on a calendar is very often a last-minute cancellation, and the second may be too. Counting from the first would make a fully booked clinic look accessible because someone happened to cancel that morning. The third open appointment is a reliable indicator of real, sustained capacity, and it is the measure the Institute for Healthcare Improvement and most health systems that track access have used for two decades.

In the plan this number is generated automatically from the appointment-availability feed that every provider must publish (see the plan, "What modern technology makes possible"), not self-reported. It is published by facility and by service line. It is the trigger for the guarantee, the trigger that closes the temporary fast lane for a given service once the guarantee is being met, and the first real-time national measurement of how long Americans wait for care, which the country has never had.

Letting people pay to be seen sooner: the Australian settlement

The plan lets anyone pay to skip the queue for a covered service, and it does so for a political reason it states openly: the people who get fast care today will not accept a plan that takes it away, and they have killed every plan that tried. The question is whether a paid lane can coexist with a universal system without hollowing it out. Australia's experience says it can, under rules.

Australia's Medicare covers every resident for hospital care as a public patient, free at the point of use, with a queue for elective surgery that in the public hospitals can run months. Alongside it, roughly 45 percent of Australians hold private hospital insurance, which buys treatment as a private patient, in a private hospital or a private bed, with a surgeon of their choosing and without the public wait. The government actively supports the private tier, with a rebate on premiums and a tax surcharge on higher earners who do not hold private cover, on the reasoning that every privately treated patient is one fewer in the public queue. The public system remains universal, and no Australian loses it by buying private cover. Ireland runs a similar two-tier arrangement, with a larger share of elective work done privately.

The Australian record also shows the failure mode the plan's rules guard against. Surgeons who work in both systems earn far more per hour privately, and public elective lists in some specialties have grown long precisely because the hours went where the money was. Australia manages this mostly through the public hospitals' own employment contracts and through the sheer size of the public sector; it has no rule tying a provider's private volume to its public volume. The plan adds that rule, and the other guardrails set out in the plan: the access fee is published in advance, a share of it funds public capacity, a provider whose public share in a service line falls below its own baseline loses the right to sell speed in that line until it recovers, and urgent care cannot be bought. The public payer pays the same schedule price for an expedited service as for one that waited, so the fast patient pays for the speed and never twice for the care.

The remaining rules are the ones every system with a private tier relies on.

• Private coverage is supplementary, never substitutive. Everyone is in the public system and pays for it regardless of what else they buy. This is the Canadian, Japanese, and Australian rule alike.
• Private facilities pay a training levy when they employ publicly trained clinicians. The private tier pays for the workforce it draws on.
• The waiting-time data is public. Days to the third next available appointment, by facility and service line, shows where the public queue still exists and where the paid lane has withered because there is nothing left to buy. Nothing closes the lane by decree; the data shows when the capacity has made it pointless.