The Premise in One Line
Collective solvency: a shared capacity to absorb risk without bankrupting people—implemented through a neutral clearing layer that settles truth before money moves.
Insurance tries to pool risk but monetizes uncertainty. A clearing layer pools truth—costs, rates, and rules—so risk can be allocated transparently and humanely.
What Collective Solvency Means
- Means‑based contribution: nobody pays beyond capacity; contributions scale with income or agreed policy.
- Transparent settlement: every transaction clears with verifiable cost elements—acquisition, fees, margin, member share.
- Corridors, not caps: prices float within published corridors to reward efficiency while preventing predation.
- Dividends of wellness: captured surplus funds lower premiums, debt relief, or community benefits.
Meet the HCC: A Civic Utility
The Healthcare Clearing Commission is the institutional form of collective solvency. Think NASA‑like mission (independent, public‑minded) and DTCC‑like function (clearing and settlement).
What it does
- Runs the Universal Clearing Layer (UCL): verifies parties, cost components, corridor prices, and member shares.
- Administers a Shared‑Risk Vault (SRV) for catastrophic costs, rebalancing exposure across plans and regions.
- Operates Transparent Arbitration: disputes resolved in public with published precedents.
- Publishes open dashboards and audit trails; updates corridor logic in the open.
What it does not do
- It does not deliver care, set clinical practice, or replace clinicians.
- It does not become an insurer; it’s the rail on which plans and payers settle fairly.
- It does not dictate politics; it provides technical governance and verifiable truth.
Not Single‑Payer, Not Pure Market
We often frame reform as a binary: centralize everything (single‑payer) or consumerize everything (pure market). The HCC is a third path: infrastructure that any payer—public or private—uses to clear transactions with integrity.
| Dimension | Single‑Payer | Pure Market | HCC (Civic Utility) |
|---|---|---|---|
| Who pays? | Government as sole payer | Individuals/employers; fragmented plans | Any payer can participate; clearing rules are universal |
| How are prices set? | Central schedules/negotiations | Contract-by-contract; opaque spreads/rebates | Public reference cost + corridor float (e.g., ±15%) |
| Innovation risk | Risk of over-central constraint | Risk of predation/price spirals | Bounded competition: rewards efficiency; prevents extraction |
| Transparency | Varies; may be administrative opaque | Low; contracts + rebates private | High: cost stack, margins, member share cleared on-ledger |
| Human layer | Depends on program design | Often transactional; burden on patients | Thank‑You Economics + public dashboards + open arbitration |
The HCC doesn’t replace payers; it replaces the fog. It is plumbing, not a party.
How It Works (10,000‑ft View)
- Enumerate the node: a drug, diagnostic, or procedure becomes a Node with a reference cost informed by actuarial data.
- Clear the transaction: provider → payer → member settlement flows through the UCL with the cost stack recorded.
- Apply the corridor: allowed price floats within a published corridor; outliers route to arbitration.
- Settle risk: routine care clears locally; catastrophic cases trigger SRV layers.
- Publish the truth: dashboards and precedents update in the open; algorithms are open‑sourced and audited.
We’ll detail the mechanics in Spoke 3: The Blueprint.
What Changes for Stakeholders
- Patients: coinsurance based on net, not list; gratitude notifications when cost‑saving choices help others; no surprise bills.
- Clinicians: fewer “coding acrobatics”; transparent authorization rules; faster settlement.
- Employers/Plans: predictable admin cost; audit‑ready ledgers; option to contribute to SRV and receive dividends of efficiency.
- Manufacturers: compete inside corridors on value and reliability; outcome data links to corridor updates instead of rebate side‑deals.
- PBMs: evolve into plan operating systems that provide service modules on top of the UCL—paid for stewardship, not spread.
Why This Is Feasible
Pieces already exist: transparent drug pricing pilots, direct‑care subscriptions, open standards like FHIR, and public cost databases. The HCC assembles these into one civic architecture with guardrails: means‑based contribution, transparent arbitration, and capped gain by service class.
Practitioner Appendix: Technical Chops
A) The Model Contrast (Deeper Cut)
- Single‑Payer: central payer & schedule → administrative simplicity but risk of over‑constraint; innovation gated by national process.
- Pure Free‑Market: contracts + rebates → high variance; innovation can thrive but with predatory pricing risk.
- HCC Infrastructure: protocolized settlement → any payer can plug in; prices float within corridors; margin caps; open arbitration; human committees ratify model updates.
B) Interoperability & Governance
- Standards: UCL speaks FHIR for clinical context; X12/NCPDP mapped for billing/pharmacy; Nodes extend beyond NDC/HCPCS to include cost stack metadata.
- SRV math: contributions tiered by income bands; catastrophic layers reinsured nationally; quarterly rebalancing using pooled variance.
- Algorithm transparency: corridor updates proposed by open models, audited by the AI Ethics Office, ratified by mixed professional/public committees.
C) Why Both Public & Private Payers Benefit
- Shared rails lower admin cost for governments and employers.
- Public programs retain policy control; private plans retain benefit design—both settle on the same truth.
- Innovation shifts from rebate arbitrage to quality inside corridors.
Next — Spoke 3: The Blueprint — Inside the Four Components
Missed the setup? Start with Spoke 1: The Failure We All Feel, or return to the HCC Hub.