John W Beck, PhD

Overview

The American people demand a Universal Health Care system that achieves:

• Universal coverage
• Equitable access
• High quality outcomes
• Administrative simplicity
• Cost control and affordability with low tax burden
• Operational resilience and auditability
• Continuous monitoring and improvement.

American Expectations

The expectation of the American taxpayer is a system that delivers:

1. Universal coverage with minimal barriers to enrollment and use
2. Affordability (lower out-of-pocket burden; predictable costs)
3. Better outcomes (preventive care, chronic disease management, maternal health, mental health)
4. Equity (reduce disparities by income, race, geography, disability status)
5. Administrative simplification (reduce duplicative billing, eligibility churn, and overhead)
6. Timely access (improve primary care and essential specialty access)
7. Financial sustainability through cost controls and payment reform
8. Auditability and integrity (traceable requirements, measurable KPIs, transparent reporting).

American Healthcare Requirements

Minimum System Requirements

Coverage and Eligibility:

• Support universal eligibility determination and enrollment pathways (auto-enroll where legally permissible)
• Reduce churn (continuous eligibility policies, simplified renewals)
• Support special populations (children, seniors, disability, veterans, undocumented per program rules).

Benefits and Access:

• Standardized essential benefits baseline; configurable state supplements (if allowed)
• Network adequacy and access monitoring
• Transparent member materials and digital self-service.

Provider and Payment:

• Provider enrollment and credentialing workflow
• Payment models support (fee-for-service + value-based arrangements)
• Claims processing with clear adjudication rules and explanations of benefits (EOB)
• Provider dispute resolution and appeals.

Prescription and Medical Necessity Controls:

• Formulary governance support
• Prior authorization minimization strategies
• Evidence-based policy updates with traceable change control.

Member Support and Appeals:

• Omnichannel contact center support (phone, chat, secure messaging)
• Appeals and grievances workflows with SLA tracking and reporting
• Language access and disability accommodations.

Data and Interoperability:

• Interoperability with providers, pharmacies, labs, and state systems
• Robust master data management (member, provider, plan, service)
• Standards-based exchange (Offeror to propose standards approach).

Fraud, Waste, and Abuse (FWA):

• Pre- and post-payment controls
• Anomaly detection, audit trails, case management
• Recovery workflow and reporting.

Non-Functional Requirements

Security and Privacy:

• Compliance with applicable federal requirements (Offeror to enumerate)
• Role-based access control, MFA, encryption at rest/in transit
• Logging, monitoring, SIEM integration
• Privacy-by-design and data minimization
• Security incident response playbooks and testing.

Resilience and Availability:

• High availability and disaster recovery (RTO/RPO targets proposed)
• Continuity of operations planning
• Stress testing and capacity planning.

Performance:

• Eligibility and enrollment response times
• Claims throughput and latency requirements
• Contact center SLA support.

Auditability:

• Traceability from policy --> requirement → implementation → test → KPI
• Evidence generation for audits (immutable logs where appropriate).

Countries Top Ranked for Best Universal Healthcare

Top-ranked countries for having the best universal healthcare often excel in access, equity, and outcomes. Australia, Netherlands, and the UK are at the top for overall system performance, though specific rankings vary by report and metrics.

• Australia: Often ranks first overall for strong access, equity, and health outcomes.

• Netherlands: Praised for its accessible system with quick access to basic care and strong performance in efficiency.

• United Kingdom (UK): Known for excellent administrative efficiency and good overall performance, despite some variations in care process rankings.
  
• New Zealand: Consistently ranks high, particularly in care process and health outcomes.
  
• France: Offers high-quality care, balancing public and private options, and is noted for low ER wait times.
  
• Canada: A strong performer overall, though sometimes noted for longer wait times for specific procedures.
  
• Sweden & Germany: Both highly regarded for quality, equity, and broad coverage, with Germany often cited for strong innovation.
  
• Taiwan: Recognized for its comprehensive, affordable system and preventing medical bankruptcy.

Key Characteristics

• Universal Coverage: Everyone has access to care, regardless of ability to pay.
• Strong Primary Care: Emphasis on accessible general practitioners.
• Cost Control: Systems manage costs effectively, preventing catastrophic medical debt.