The four that carry the most weight
Each of these would change what the program is, not merely how fast it runs.
Structural acts signed
Fewer than 4 of 8
Publish the pessimistic scenario as the operating plan. Stop promising a delivery arm. Revise the cost target upward.
Without the chartering statute this is a different program: universal coverage financed federally, delivered by the existing private system, with no public delivery arm and no rate authority.
Bypass rate
Rising in more than 20% of rural catchments
Capacity payments are set too low or capability thresholds too weak. Reprice before facilities close.
Bypass moves roughly two years ahead of the balance sheet. It is the earliest signal available and it reads from claims data continuously.
Access-adjusted spending against cash
Gap exceeds 1.5 points of GDP
Price compression is outrunning delivery. Pause the glide path; redirect to capacity.
Cash savings from undelivered care are the failure that looks like success on the ledger. This trigger is the reason the cost brake reads access-adjusted rather than cash.
Commercial rate convergence
Less than 40% of scheduled compression by 2038
The fiscal case fails. Publish a revised cost target rather than defending the old one.
Price compression exceeds the entire net saving. Halved, the program costs more than current law — a reversal of sign rather than a narrowed advantage.
All twelve lines
Checked on the stated cadence and published whether or not they are crossed.
| # | Measure | Line | Checked | Action required if crossed |
|---|---|---|---|---|
| 1 | Structural acts signed | Fewer than 4 of 8 | End 2030 | Publish the pessimistic scenario as the operating plan. Stop promising a delivery arm. Revise the cost target upward. |
| 2 | Claims platform milestone completion | Below 50% at month 42 | Mid 2033 | Switch permanently to contracted administration on the Medicare 1966 model. Add operating cost, cancel the remaining build. |
| 3 | Authorities chartered | Fewer than 60 by end 2033 | End 2033 | Extend chartering to smaller entities and accept a larger count with weaker management. Fund an interim management contract pool. |
| 4 | Payroll tax receipts against projection | Below 88% for two consecutive quarters | Quarterly from 2031 | Audit the qualifying-coverage credit. Tighten the standard by regulation. |
| 5 | Bypass rate | Rising in more than 20% of rural catchments | Annually from 2033 | Capacity payments are set too low or capability thresholds too weak. Reprice before facilities close. |
| 6 | Rural obstetric units, net change | Net negative in any two consecutive years | Annually from 2032 | Emergency capacity-payment increase for obstetrics and an accelerated transport build in the affected catchments. |
| 7 | Access-adjusted spending against cash | Gap exceeds 1.5 points of GDP | Annually from 2035 | Price compression is outrunning delivery. Pause the glide path; redirect to capacity. |
| 8 | Rural generalist enrolment | Below 400 entering per year at 2034 | Annually from 2032 | Accelerate the foreign-trained bridge, raise the rural differential, expand bonded places. |
| 9 | Nurse staffing compliance | Below 85% of authority facilities | Quarterly from 2034 | Global-budget rebase paused for non-compliant facilities. Faculty funding raised. |
| 10 | Authorities in receivership | More than 12% concurrent | Annually from 2035 | The resolution corps is undersized or capacity payments are mispriced. Both are correctable. |
| 11 | Utilization-management displacement | Retraining placements below 40% of separations | Annually from 2031 | Fund direct placement into authority administration and care coordination. |
| 12 | Commercial rate convergence | Less than 40% of scheduled compression by 2038 | Annually from 2034 | The fiscal case fails. Publish a revised cost target rather than defending the old one. |
Which acts need sixty votes
Vehicle determines vote threshold, and vote threshold determines what survives a narrow trifecta. 8 of 15 acts need sixty votes. If they fail, the program has money, a floor definition, and no institutions — universal coverage financed federally and delivered by the existing private system, with no public delivery arm and no rate authority. That is the most likely failure mode, and it is a different program rather than a slower one.
| Act | Vehicle | Votes | Baseline | If it fails |
|---|---|---|---|---|
| Payroll tax and credit structure | reconciliation | 51 | 2029 Q4 | All financing |
| Benefit outlays and floor definition | reconciliation | 51 | 2029 Q4 | The floor itself |
| Capital appropriation | reconciliation | 51 | 2029 Q4 | All construction |
| AHQB enabling act | regular order | 60 | 2030 Q3 | Coverage determination and rate-setting. The program runs on Medicare rules indefinitely. |
| QALY prohibition repeal | regular order | 60 | 2030 Q3 | AHQB methodology. The Board cannot publish thresholds. |
| RHA chartering statute | regular order | 60 | 2030 Q4 | All public delivery. Deserts stay unserved. |
| All-payer rate authority | regular order | 60 | 2031 Q1 | Global budgets outside AHEAD states |
| Medicaid medical absorption and the per-state bridge | reconciliation | 51 | 2030 Q2 | The Medicaid tranche and the maintenance-of-effort bridge that prevents early shedding |
| Liability preemption | regular order | 60 | 2032 | The clinician bargain. The price glide path softens. |
| GME cap repeal | reconciliation | 51 | 2030 Q2 | Physician supply expansion |
| Federal shortage-area licensure | regular order | 60 | 2031 Q2 | Workforce mobility and the foreign-trained bridge |
| Self-referral repeal | regular order | 60 | 2031 Q4 | Over-provision control |
| Employer exclusion repeal | reconciliation | 51 | 2034 | Supplemental market sizing |
| Hyde repeal and reproductive preemption | regular order | 60 | 2031 | National reproductive coverage. Access varies by state. |
| FEHB termination | reconciliation | 51 | 2033 | The universality rule |
The rollout timeline and the annual budget flow from the same model are not published here. Both are held pending reconciliation against the fiscal scoring engine — the model's optimistic maturity target and the site's differ by more than two points of GDP, and its payroll-receipt column implies a healthcare payroll silo the architecture rejects. See methodology for how the scoring engine is built.