ATTENTION To each returning visitor to NATIONAL HEALTH and to each new visitor, I am announcing that this set of essays has been newly edited and published as a book. Its title is:
BETTER HEALTH FOR AMERICA.
The 320-page book includes a newly edited version of this website and a unique, trending analysis of our nation’s maternal mortality incidence (see Sub-Chapter 7c). The book has been offered for sale on Amazon since April 8 of 2021. A KINDLE version has been available since April 12, 2021.
WARNING: READER BEWARE!
If you chose to read this book, I propose that you accept a certain personal responsibility. Please accept a responsibility to offer Kindness and Respect to every person that you safely encounter every day. Kindness and respect is especially important when interacting with
- women before, during, and after a pregnancy,
- every infant,
- each disabled person, and
- the possibly homeless.
When expressed within your family, your neighborhood, and your adjacent communities, this shared Kindness and Respect builds trustworthy communities. Improving social cohesion then promotes each community’s healthy survival during the bad times as well as the good times.
Finally, every person needs to steadily update their adaptive skills for living in our complex society. Interpersonal stigmata must not be allowed to disturb our mutually shared expressions of Kindness and Respect. Every reader will now understand the complexity of this personal responsibility.
Remember, good things are possible ALTOGETHER.
Paul J. Nelson M.S., M.D.
May 27, 2021
– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – –
for healthcare reform
NATIONAL HEALTH
To improve our nation’s population HEALTH
and its healthcare, ALTOGETHER
INTRODUCTION
“Never doubt that
a few committed people can change the world.
In the end, it’s the only thing that ever has.”
Margaret Mead (1901 – 1978)
“It’s better for everyone
when it’s better for everyone.”
Eleanor Roosevelt (1884 – 1962)
“To create long-lasting social change,
organizations and the programs they create
must in one way or another
become embedded in the local community.”
Eric Nee (1954 – )
MODERN HEALTHCARE BEGAN . . .
Before 1850, healthcare usually occurred within the home of each person’s Family. Historically, the healthcare exceptions only occurred with hunting/gathering, war-time, or poverty as in homelessness. After 1850, the location for the advancements of healthcare slowly began to move out of a person’s home and into another institutional location. During the next 170 years, healthcare eventually became the responsibility of persons who had decreasing connectedness with the person. The decreasing interconnectedness within healthcare is notable by the pervasive absence of any spontaneously expressable awareness about a person’s Family or their Extended Family, Family Traditions, and micro-social networks.
The use of infection control and anesthesia for surgery began this process of change for a person’s healthcare from the home of a person’s Family to a healthcare institution. The history of this transition has also interacted with the social, economic, and scientific trends underlying our nation’s heritage. The increasingly scientific and economic basis for healthcare is now associated with institutional governance problems within our nation’s healthcare industry, especially its domineering level of economic concentration. For a community, each person’s Family has lost an important tradition for sustaining its caring relationships with the members of their Extended Family and its micro-social networks.
- COMMENT: In effect, the historical evolution of healthcare mirrors our nation’s evolving cultural and ecologic traditions that have jeopardized the resilience of each community’s social cohesion and its attendant social capital. Along with many contributing social changes, a decrease in the prevalence of trust, cooperation, and reciprocity has occurred during the last 170 years among the social networks of most communities. The decline in many community’s prevalence of trustworthy persons is best explained by the declining collaboration that is occurring between adjacent communities to invigorate the social capital of each other’s Survival Commons (aka, enhanced safety net).
a NEW STRATEGY
To augment each community’s Survival Commons, our nation’s healthcare industry will require a new strategy to resolve its current level of paradigm paralysis. This new strategy should offer nationally structured, collaborative assistance to each of nearly 800 contiguous communities. Locally managed and funded, a community based new strategy would begin with a special focus on the equitable availability of Primary Healthcare that is offered within each community to its resident persons. Eventually, this national renewal of Primary Healthcare, community by community, will be necessary to help resolve the cost and quality problems of our nation’s healthcare.
- COMMENT The analysis offered within the Blog has coincided with a refinement of thirteen concepts. Where important to prevent cognitive dissonance, these concepts can be identified by the use of italics within the essays of the Blog’s 54 PAGES and Sub-Pages. These concepts represent the inter-connected definitions for a caring relationship, cluster, collective action, community, disruptive process, Family, HEALTH, person, social capital, social cohesion, social dilemma, social interaction, and Survival Commons (aka augmented safety net).
- COMMENT A hypothetical set of definitions for the 13 concepts can be found by clicking on the RATIONALE Sub-Page. This Sub-Page can be located on the list of the Blog’s Pages and Sub-Pages located on the grey panel to your right. You will need to scroll to the top of this HOME Page to find it. You will be transferred immediately to that Sub-Page by clicking on it. Assuming you might print this Sub-Page, the set of 13 definitions begins on its 4th page.
REFORM THROUGH INSTITUTIONAL CHANGE – Stage One ( 1 year ) 2022-2023
“We must, indeed, all hang together
or most assuredly we shall all hang separately.”
Benjamin Franklin (1705 – 1790)
MUTUAL BENEFICENCE
As they were about to sign our nation’s Declaration of Independence, one can only imagine the profound level of resolve among the members of the Second Continental Congress that convened in 1776. The meaning of the words above, spoken then by Benjamin Franklin, eventually became prophetic as borne out subsequently by history. At a much different point in time almost 250 years later, I now propose that the sentiment of Benjamin Franklin should represent the level of precision that will be necessary for the actual reform of our nation’s healthcare industry. We will need a higher level of broadly expressed trust, cooperation, and reciprocity within every community to resolve the locally occurring social adversities that ultimately cause the problems within our nation’s population HEALTH.
- COMMENT A new semi-autonomous institution, NATIONAL HEALTH, will be required. The new institution would be Chartered by an act of Congress and instituted thereafter within 6 months, presumably in 2022. The Charter would prohibit any involvement by NATIONAL HEALTH in the actual disbursement of financial capital or any other form of financial support for healthcare. Its governance would be structured to acknowledge the needs of and collaboration by each individual State and its communities. Finally, it would be Federally financed with a fixed budget of $1.50 per citizen per year, annually adjusted for inflation. A proposal for the initial Governance of NATIONAL HEALTH can be found under the GOALs Page by a Sub-Page with the title of initial GOVERNANCE.
- COMMENT The Congressional Charter for NATIONAL HEALTH would include a 10 year, sunset provision if its GOALs were not met. At the end of 10 years, three specific GOALs would require affirmative certification by the President to Congress. They are:
- Decrease health spending slowly as a portion of our national economy to 13.0% or less of our nation’s annual Gross Domestic Product (a decrease that would have represented a decrease of 27% in 2018). The change in health spending would progressively evolve by implementing three National Projects and a decentralized, community-driven new strategy for restraining health spending to a level that is just below annual economic growth;
- Decrease our nation’s annual maternal mortality incidence by 70%; and
- Achieve full participation by all States as approved by their respective State legislature.
GOVERNANCE
As implemented by its semi-autonomous Board of Trustees, NATIONAL HEALTH would implement three national projects to improve Primary Healthcare. The three national projects will be augmented by a new strategy to promote community by community collaboration for enhancing their locally-focused Survival Commons (viz, locally augmented safety net) beginning with the equitable availability of its Primary Healthcare.
The NATIONAL HEALTH Initiative Page and its 5 Sub-Pages describe its anticipated structure and function. There is a preliminary initial STRATEGIC PLAN Sub-Page under the GOALs Page for the initial Tasks of NATIONAL HEALTH.
- COMMENT For the purposes of NATIONAL HEALTH, each community is intended to represent on-average about 400,000 resident persons. Conversely, for sparsely populated areas, a community might comprise only 100,000 resident persons. Ultimately, NATIONAL HEALTH would be most broadly identifiable by its efforts to promote nearly 800 Community HEALTH Forums. Establishing and implementing the tasks of each community’s Forum can be understood as described by the communityHEALTHforum Page and its Sub-Pages. These Forums would implement the new strategy to reform every resident person’s healthcare.
- COMMENT To steadily improve the national fabric of Primary Healthcare that is offered locally, three National Projects will be required.
- First, NATIONAL HEALTH will establish a Basic Health Benefits Plan to define the minimum benefits qualified for their reimbursement by all the public and private economic sources, at all levels, that support Basic as well as Complex Healthcare. This Plan will also provide a basis for the augmented financial support of each Primary Healthcare clinic that qualifies for HEALTH SECURITY certification. NATIONAL HEALTH would have no involvement with any pricing attributes of these minimum benefits.
- For the second national project, a HEALTH SECURITY certification process will be established to identify the Primary Healthcare clinics that qualify for augmented reimbursement based on their verifiable, operational standards. A model for this certification process is described by the last Sub-Page of the GOALs Page.
- Finally, NATIONAL HEALTH will identify the essential stakeholders for a nationally implemented, career-long, professional growth process for the physician, physician assistant, and nurse practitioner members of every HEALTH SECURITY certified, Primary Healthcare clinic. The self-directed and mentored professional growth process for each physician or associate would begin during their under-graduate and post-graduate medical education. It would coordinate with, viz. possibly replace, any maintenance-of-certification process maintained by the Board of Medical Specialties for Primary Physicians.
GETTING STARTED
Given Congressional authorization and Presidential approval, the initial Meeting of the NATIONAL HEALTH Board of Trustees could occur within 6 months of the Congressional Charter’s approval by Congress and the President. During 2022, the initial Meeting and its subsequent Meetings would be held at a Home Office located in St. Louis, Missouri. It is the largest city that is both nationally accessible and located closest to the geographic population center of the United States. The Congressional Charter for NATIONAL HEALTH would include a process for initiating the initial Meeting of its Board of Trustees. See the “initial GOVERNANCE” Sub-Page of the GOALs Page for a possible model.
The Board of Trustees will form nine consulting Regional Councils, each encompassing a State or group of States with approximately 36 million resident persons. The Regional Councils would in-turn form 9 District Coalitions (a total of 81), each District Coalition encompassing 4 million resident persons. The District Coalitions would offer technical assistance and training for the formation of nine Community HEALTH Forums, each encompassing @400,000 resident persons. Decentralized governance would prevail. Each of the nearly 800 Forums would, in turn, establish a community gathering process for 9 key stakeholders or Advocates to prepare an annually reviewed and revised Community HEALTH Plan (see the communityHEALTHforum Page for details) including a Master Disaster Mitigation Strategy for improving its Survival Commons.
STABILIZE HEALTH SPENDING – Stage Two ( 4 years ) 2023-2027
GOALS
Among many conflicting issues, the ultimate problem of our nation’s healthcare is its cost as a portion of our national economy. In 1960, health spending represented 5.0% of our national economy as measured by its GDP. For 2019, health spending represented 18.0% of the GDP. During the intervening 60 years, health spending as a portion of our national economy increased by 2.16% compounded annually. The increase is variably 0-2% more than economic growth, compounded annually.
Using data from the Organization for Economic Co-operative Development (OECD) and its 35 member nations, we learn that the other 34 nations have health spending that is less than 13% of their GDP in 2018. Using 13% as a GOAL for our nation’s health spending and 18.0% of our GDP in 2018, the excess health spending for our nation in 2018 would have represented $1.008 trillion. This excess health spending was the equivalent to the cost of waging 10 Iraqi/Afghanistani Wars simultaneously during 2005.
The slowly progressive, increase in health spending has now compromised the ability of our nation’s Federal Government to support education and infrastructure development. It is known that spending on education has a return on investment (ROI) for economic growth of 3:1, 7:1 for early childhood education, and 5:1 for anticipatory disaster mitigation projects, such as flood control. Most importantly, the increased contribution to our nation’s health spending paid by the Federal treasury (Medicare and Medicaid) represented 58% of our nation’s Federal fiscal deficit for 2018 and 50-60% during several interval years prior to 2018. In effect, our nation’s Federal government is headed to bankruptcy principally from the burden of our nation’s health spending because of its annual increase that is larger than economic growth.
- COMMENT: Initially, each community’s Forum will evaluate the adequacy of its own equitably available, Primary Healthcare. The local accountabilities for resolving the patterns of deficiency will be evaluated and a long-term plan for their resolution will be established. Each Forum’s long-term Plan will reflect a collaborative effort involving its locally prominent stakeholders. Nearly 800 community Forums would be required, each defined for a population of approximately 400,000 resident persons. NATIONAL HEALTH would offer consultation and training support to each community’s Forum. The ongoing administrative support for each Forum would come from within their own community.
COMMUNITY CENTERED
The long-term function of each Community HEALTH Forum would focus on promoting an adequate level of social capital within their own and their adjacent communities. Ultimately, this would begin with a responsibility to define their own community’s Survival Commons and its responsiveness to the needs of its resident persons. Achieving Stable HEALTH for each resident person begins with a recognition that the basic ecologic and cultural origins for Unstable HEALTH are rooted within each resident person’s community.
Six years after the initial Meeting of the Board of Trustees, the portion of the GDP allocated to ‘health spending’ will have stopped increasing faster than economic growth for 1 or more years. This may be solved ultimately by an increased rate of economic growth as promoted by the slow decrease of the historically annual increase in health spending, especially when health spending no longer contributes to our nation’s annual fiscal deficit.
Stable HEALTH for Each Resident Person – Stage Three ( 5 years ) 2027-2032
SOCIAL CAPITAL
The institutional decentralization and health spending issues should be considered as preliminary phases for solving the social cohesion deficits underlying our nation’s HEALTH. Many of these have root causes that originate from within the “…mindless menace of violence…” that afflicts most communities. For a moment, read the short “Mindless Menace” Sub-Page of the APPENDIX Page. The processes for improving the level of social cohesion within each community will be unique given their own ecologic and cultural traditions. Defining these locally occurring root-causes will be required as the basis for reducing the prevalence of violence within the municipal life of each community.
I propose that our nation’s annual incidence of maternal mortality should be the most important attribute of our long-term progress for the improvement of childhood maltreatment, childhood obesity, adolescent suicide/homicide, substance addiction/mortality, mass shootings, homelessness, mid-life depression/disability, and our nation’s stagnant longevity at birth since 2010.
The OECD (Organization for Economic Cooperation and Development) regularly reports maternal mortality ratio (MMR) trends among its 35 member nations. From 1990 thru 2014, the average maternal mortality incidence of the OECD nations decreased from 32 to 14 deaths per 100,000 live births. For the United States, our maternal mortality ratio during the last 30 years has steadily worsened. Our nation’s MMR during 2014 was 23.8 maternal deaths per 100,000 live births.
In 2014, there were 3,985,924 USA live births. The analysis of this data indicates that 948 maternal deaths occurred in 2014. It is possible to assume that at least 770 of these women died in 2014 because they were living in the wrong nation at the time of conception. If these women had been living at the time of conception within 1 of the 10 nations within the OECD with the lowest maternal mortality incidence, at least 770 of the 948 women who died in connection with a pregnancy during 2014 could still be alive. These 10 OECD nations have an average maternal mortality incidence that is 70% lower than the incidence for the United States.
- COMMENT: The State by State improvement for its available and accessible Primary Healthcare and the improved level of social cohesion from their Community HEALTH Forum activities will eventually reduce our nation’s maternal mortality ratio by 70%. This improvement will require a generational “shoot the moon” level of commitment and precision by all public and public HEALTH institutions, at all levels, especially neighborhood by neighborhood. As of 2020, many states have already initiated broadly collaborative efforts to reduce maternal mortality. Improving the Survival Commons within each community will help guarantee the success of this commitment from within our healthcare industry.
PERMANENT HEALTHCARE REFORM
NATIONAL HEALTH
Our nation’s autonomy within the worldwide market-place arenas for its Resources, Knowledge, and Human Dignity will likely require a means to plan and promote a unified process for the distant future of healthcare reform. I am continually reminded that only 10% of the world’s population outside of the USA live in a nation with our nation’s Constitutionally-guaranteed First Amendment rights of speech, religion, press, assembly, and petition. Unfortunately, I suspect that the percentage of our resident persons as a portion of the worldwide population is probably shrinking.
We should firmly recognize the pervasive level of cognitive dissonance that exists within the global marketplace arena for the Human Dignity obligations demonstrated by each of the worldwide nation-states.
- COMMENT: Our nation’s stability will become severely challenged as the world adapts another 2 Billion extra human beings by 2050 and another 1-2 Billion by 2100. Given a 7.7 billion world-wide population in 2019, the future cost and quality problems of our nation’s healthcare must have a nationally promoted, locally managed, and broadly sanctioned new strategy. Regardless of its causes, global warming could severely complicate these issues. With the worldwide pandemic of 2010, a new plan to resolve our nation’s population HEALTH problems will be absolutely required.
- COMMENT: The new strategy should be decentralized and steadily adjusted as its performance continues to evolve. We must continue to pursue improvements in the quality and cost of our nation’s healthcare. It must achieve a stable portion of our national economy that is allocated to health spending, ideally 11-12%. At that level, the funding needs for under-graduate and post-graduate medical education will need to be increasingly funded by Congressional action that justly supports both our needs for Basic Healthcare as well as for Complex Healthcare. The current process for its funding is unstable, has no means to encourage Primary Physicians, and has no means to hold our medical education institutions accountable for this.
- COMMENT: Remember again. We will need to reduce the risk of cognitive dissonance as we construct the collaborative bridges that will be required for permanent healthcare reform. Listed below, thirteen interconnected concepts are likely to align as a cluster, the Keystone lynchpin, for implementing a long-term strategy to solve the cost and quality problems of our nation’s HEALTH and its related healthcare. In association with another 40 concepts, they are all best defined and analyzed together on the “Glossary for HEALTHCARE” Sub-Page of the OVERVIEW Page.
- Caring relationship
- Cluster
- Collective Action
- Community
- Disruptive Process (root causes of each cause)
- Family
- HEALTH
- Person
- Social Capital
- Social Cohesion
- Social Dilemma
- Social Interaction
- Survival Commons (viz augmented safety net)
SUB – PAGES
PREFACE
I describe the circumstances in 2007 that prompted this Blog. Most of the Blog’s Pages and their Sub-Pages begin with a quotation. The PREFACE Sub-Page begins with a quotation from Gertrude Stein. In effect, she is saying: you will think most carefully about an idea, person, or event when you can clearly communicate about them with the written word.
Personally, I am still an advocate of the handwritten variety as documented by my eventual entry into word processing soon after reaching my 57th birthday in 1999. The process of producing a handwritten document for a “care plan” during an office visit had for many years helped me to improve the precision of defining the healthcare plan during each person’s health care appointment. This was especially necessary as a process to coordinate the healthcare for any person who required multiple medications taken at least once a day.
CONTENTS
There are eight main PAGEs for the Blog. I describe the intent of each main PAGE on this Sub-Page. Its INTRODUCTION describes a possible root-cause of root-causes for the current disarray afflicting the flawed character of our nation’s current healthcare, reform strategies.
RATIONALE
I hope you are energized AND open to considering new realms of Knowledge for a better strategy to guide our Nation’s healthcare reform. I have encountered many new realms of Knowledge as I have attempted to arrive at an expanded understanding of HEALTH. The recognition that a state of Paradigm Paralysis has afflicted our nation’s healthcare has prompted the search for a new strategy to unleash its underlying quality and sophistication.
To achieve resolution of the Paradigm Paralysis renewal, any new strategy for healthcare reform will require a new basis for reducing the cognitive dissonance associated with explaining the occurrence of population HEALTH problems. This Sub-Page introduces thirteen interconnected definitions as a basis for considering the alternative options available for implementing any new strategy.
FIVE HEALTH STORIES
The progression of increasing annual health spending during each resident person’s lifelong survival is largely unknown. This Sub-Page is intended as one Primary Physician’s view of the Unstable HEALTH for 17% (1 in 6) of our resident persons who consume 83% or our nation’s health spending. The population health spending pattern by our rank-ordered, highest to lowest, resident persons represents a Power Law Distribution curve. As a result, 83% of our resident persons consume only 17% of our nation’s total health spending.
I propose that the equipoise could be 70:30. This will require an enhanced level of Primary Healthcare with 24/7 augmented medical TRIAGE and a refinement of our nation’s health spending distribution based on the Design Principles defined and validated by Professor Elinor Ostrom. As a result, the ultimate goal for our nation’s health spending could eventually represent 11-12% of our GDP (gross national product) instead of nearly 20%.
MINDLESS MENACE
A brief essay regarding the Presidential campaign of Senator Robert Kennedy of 1967-68 a speech he gave 12 times with the last occasion in Cleveland, Ohio on the day after The Reverend Doctor Martin Luther King, Jr. died.
revision LOG
The introduction of new ideas to the Blog has occurred fitfully since the beginning of this Blog in 2008. In 2014, I began to document the pace and character of the evolving concepts underlying the NATIONAL HEALTH Initiative.
COMMENT: The revision LOG is the only Sub-Page that you can use to be identified as a follower. That way, you will be notified about “what’s new” when I have made a substantial update.
This page has the following sub pages.