enhanced Primary Healthcare
E X E C U T I V E S U M M A R Y
7.8 k — 1 —
INTRODUCTION
“In the absence of justice,
what is sovereignty but organized robbery?”
Saint Augustine of Hippo (354 – 430)
“Law and order exist for the purpose of establishing justice.
And when they fail in this purpose, they become the dangerously structured dams
that block the flow of social progress.”
The Reverend Doctor Martin Luther King, Jr. (1929 – 1968)
“Without monitoring, there can be no credible commitment;
without credible commitment, there is no reason to propose new rules.”
Elinor Ostrom (1933 – 2012)
DESIGN PRINCIPLES
The research and teaching career of Professor Elinor Ostrom spanned 40 years. With collaborative connections involving many colleagues, she clarified the Design Principles for evaluating any strategy intended to use collective action for managing a shared-use, common-pool resource, a “commons.” These Design Principles are especially useful for predicting the likely success of a strategy for the management of a finite resource that is variably accessible for its use by the members of a defined group. As a portion of her research, she studied a successfully managed commons in the state of California, viz., the fresh-water aquifer underlying the city of Los Angeles. Soon after 1930, the 5 separate counties associated with the city of Los Angeles established a collaborative connection to eventually control access to the aquifer. This collaboration began with evidence that a declining level of the aquifer for supplying the city’s water needs would eventually promote its contamination by seawater. By 1960, the original set of agreements among the 5 counties and almost all of the high-volume, water users achieved a goal of limiting extraction from the aquifer. These agreements also arranged to invest locally originating economic resources to construct access to water sources located outside the 5 counties for the future needs of the entire Los Angeles metropolitan area. Most importantly, the preservation of the aquifer from the encroachment of seawater occurred without regulatory control or economic assistance by either the State of California or the Federal government.
In addition to the Los Angeles fresh-water aquifer, Professor Ostrom studied many other “Commons,” each having developed spontaneously in diverse geographic locations and cultural communities around the world. This research focused on the equitable preservation of diverse common-pool resources (CPR) such as fisheries, mountainside forests, and rural irrigation systems. I propose that the results of this research are applicable to our nation’s economy and its ability to sustain the financial burden represented by our nation’s annually increasing. health spending as a portion of our nation’s economy (GDP). I am especially influenced by the diverse studies that verified the Design Principles that are associated with the successful management of a common-pool resource. Most importantly, she also identified the performance of voluntary institutions as having greater success for the management of a commons as compared to the actions of an authoritarian, autocratic government. In 2009, she received a Nobel Prize for political economics in recognition of her research and its significance. After a long and distinguished academic career, Professor Ostrom died in June of 2012. (Ostrom 1990)
Viewing the steadily worsening level of worldwide social, political, and economic turmoil, our nation’s Population HEALTH and its Primary Healthcare require a precisely defined, new Proposal to achieve a substantially improved level of efficiency and effectiveness. The application of a known and well-defined realm of Knowledge, new to Population HEALTH and its Primary Healthcare, must now be mobilized to improve our nation’s prevalence of our residents who live with Stable HEALTH. A Congressional Charter for a new semi-autonomous institution, NATIONAL HEALTH, describes one possible means to this end. With a New Strategy and Four National Projects, the extensive research related to successfully managing a commons represents the basis to achieve beneficial healthcare reform. Paired with a continuing reassessment of its application to healthcare reform, collective action including its variant options is our best option for releasing the paradigm paralysis characterizing the deficiencies associated with our nation’s Population HEALTH and its Primary Healthcare.
POPULATION HEALTH: Monitoring its Resilience
Referring to the quotation cited above by Professor Ostrom, the total number of hospital days used weekly by the resident persons of a community would represent the most succinct, global tool for monitoring the evolving resilience of each community’s Population Health. Nearly 810 communities, each serving the needs, on average, of approximately 400,000 resident persons, would use collective action to define their own Community HEALTH Plan. As a New Strategy, these Plans would represent a locally structured and mobilized assignment of responsibilities for the Tasks necessary to achieve Stable HEALTH For Each Resident Person, community by community. NATIONAL HEALTH would then represent a new, nationally sanctioned institution to implement and guide this local commitment for the benefit of each community’s resident persons.
To consider a new Proposal for healthcare reform, it is important to establish a clear consensus regarding the unrecognized complexities that underlie every resident person’s Stable HEALTH. Establishing a new definition for HEALTH is very complicated given the wide range of contributing factors, especially its epigenetics and social determinants during early childhood. For instance, the use of “temperament” may be new to many, even though it has been thoroughly studied in infants. The importance of early childhood education is now recognized as very important for each child’s eventual caring, learning, and creative capability, viz.., cultural social-cognition. (Tomasello 2019) Finally, the relationship between a community’s social capital, its Survival Commons (augmented safety net), and the prevalence of generational caring relationships within the community’s social networks gives a broader emphasis to the connection existing between each person’s Stable HEALTH and their community’s Social Cohesion. Eventually, the collaboratively persistent exchange of social capital contributions between neighboring communities nationwide becomes the basis for improving our nation’s Social Cohesion.
HEALTHCARE TRADITIONS: A NEW ERA ORIGINATED BETWEEN 1969 & 2009
To understand the evolving arena of Knowledge about every person’s HEALTH, a contemporary definition is required. Given the unusually wide variety of its use, it is important that the NATIONAL HEALTH Proposal recognizes a single definition for HEALTH. To reduce the occurrence of cognitive dissonance, here is a possible alternative;
HEALTH may be postulated as
a person’s daily experience of lifelong Well-Being
that occurs when the resilience of the person’s survival has been
^
A. Endowed initially by the maternal, Family Traditions existing before conception and
subsequently by the gestational formation of synergy between
the person’s innate temperament and the person’s baseline homeostasis to achieve
adequate resilience for the person’s continuing survival immediately after birth and
thereafter by a Personal Survival Plan originating from within their Family;
^
B. Nurtured by the person’s caring relationships that originate from within
the person’s Family, its Family Convoy, and their Home’s close neighborhood
1) during their early childhood development with a goal to enrich the person’s search
for the broadest portrayal of their uniquely-endowed Human Capability
while becoming a joyful ‘dependent person’ and
2) during their late childhood, adolescent, and early adulthood development
with a goal to mentor the person’s simultaneously evolving
personality, moral reasoning, and self-esteem for the broadest portrayal
of their uniquely-endowed Human Capability while becoming
a courageous, sustainably self-sufficient ‘independent person’ after adolescence;
^
C. Challenged by the person’s daily encounter with disruptive processes
involving discordant social interactions that begin before birth,
occur as interacting combinations and patterns, and
cause variably reversible and either beneficent or maleficent changes
to the adaptive resilience of the person’s uniquely-endowed Human Capability,
its innate temperament, and its baseline homeostasis
as variously prevented, mitigated, and ameliorated lifelong
by the joyful caring relationships originating from within
the person’s Family, its Family Convoy, and their Home’s close neighborhood;
^
D. Matured by the person’s episodic encounter with disruptive processes
involving diversely traumatic, baseline homeostatic changes that begin before birth,
occur as interacting combinations and patterns, and
cause variably irreversible and maleficent changes to the adaptive resilience
of the person’s uniquely-endowed Human Capability, its innate temperament, and
its baseline homeostasis as variously prevented, mitigated, and ameliorated lifelong
by the courageous caring relationships originating from within the person’s Family,
its Family Convoy, and their Home’s close neighborhood; AND
^
E. Sustained by the hopeful caring relationships originating from within their Family,
its Family Traditions, its Family Convoy, their Personal Survival Plan, and
the Survival Commons of the person’s community until the continuing resilience
of the person’s uniquely endowed Human Capability is no longer sufficient to maintain
the person’s survival as a result of their lifelong encounter with disruptive processes.
Before 1969, a stomach ulcer, heart attack, or measles eventually afflicted at least someone within every family and its family convoy. During 1969, healthcare for the prevention or treatment of these illnesses did not exist. Today, a stomach ulcer can be prevented with medication, healed without surgery, and prevented by avoiding certain over-the-counter medications or dietary patterns. Now, death from a heart attack can be reliably prevented by a special combination of 4 generic medications. And, a devastating measles epidemic every seven years no longer occurs. Since 1969, our nation’s healthcare traditions have established these and many other outstanding improvements to achieve Stable HEALTH For Each Resident Person. In spite of these achievements, our nation’s Population HEALTH and its Primary Healthcare have profoundly troubling problems.
These problems are largely the result of traditions that began nearly 170 years ago with the initial use of anesthesia and sterile conditions for surgery. By around 1870, the advent of safe surgery and the knowledge required to prevent infection had led to the initial evolution of hospitals as a place for this surgery and its related healthcare. In effect, the occurrence of health care primarily by each person’s family and family convoy at home has progressively become replaced by another location as provided primarily by strangers. It is possible that the original health care of each person at their home was before 1870 was associated with an improved participation in their family traditions by the members of each person’s family and its family convoy, especially during recovery. In effect, the traditions related to the evolution of hospital-based, healthcare may have actually diminished the participation of family members in the healthcare needs of another family member and thereby diminish that role within their family traditions. Eventually, the importance of each person’s family has become adversely affected by certain other ecologic factors such as the prosocial decline within neighborhood social networks, decreasing participation by the non-profit institutions within each community’s municipal life, women’s employment, the prevalence of poverty, homelessness, substance addiction, and the decline of family mealtime obligations.
COORDINATING A “COMPLEX ADAPTIVE SYSTEM”
Certainly, there is widespread agreement regarding the need to reform our nation’s healthcare traditions and possibly to establish new traditions. Even with the Accountable Care Act of 2010 (Obamacare), lingering disagreements still widely exist regarding the priorities necessary to reform the historic traditions of our nation’s healthcare industry. Most importantly, we have lost a clear recognition that each resident person’s family, their family traditions, their family convoy, and their home’s close neighborhood must be acknowledged within our nation’s Population Health traditions.
Increasingly, our healthcare industry has needed a New Strategy to redirect its traditions as a basis to prioritize the Basic Healthcare Needs of every resident person. This New Strategy is especially necessary since the healthcare for many resident persons has become increasingly complicated since 1969. The increasing level of complexity is associated with advanced improvements that would have been unimaginable in 1969. Unfortunately, a nationally sanctioned and widely supported strategy does not currently exist to assure that these improvements are both equitably available to as well as ecologically and culturally accessible by every resident person within each community.
Our nation needs a new, nationally sanctioned institution with strong regional and community connections to collaboratively identify and define the diverse reforms necessary to release the untapped excellence of our nation’s healthcare for Complex Healthcare Needs. Most importantly, this new institution should sponsor its reform strategy primarily for every person’s Basic Healthcare Needs to promote their Stable HEALTH, community by community. Lacking this institution, our healthcare industry will continue to suffer from the effects of the paradigm shift that began in 1969. The paradigm shift occurred as the result of a progressively increasing proportion of our nation’s resources that are allocated to the Complex Healthcare Needs of each resident person. This increase coincided with a steadily declining portion of our nation’s resources justly and equitably allocated to the Basic Healthcare Needs of each resident person. During 2017 (MEPS #528 2020), a Federal study ranked our nation’s resident persons according to their estimated health spending from most to least. The lowest 165 million resident persons (50%) on average accounted for health spending of $640 each.
In response to this paradigm shift, a New Strategy and Four National Projects are especially necessary to assure the future improvement of our nation’s Population Health and its Primary Healthcare. This EXECUTIVE SUMMARY Page describes a clearly defined and precisely focused Proposal for a new semi-autonomous institution, NATIONAL HEALTH. Chartered by Congress, NATIONAL HEALTH would begin with a general mandate to foster a continuously self-reforming healthcare industry to eventually represent a collaboratively maintained Complex Adaptive System. To limit the scope of the initiating NATIONAL HEALTH Proposal, its budget would be fixed at a national cost of $1.50 per resident person per year, inflation and population-adjusted annually. With an annual budget of nearly $500 million, the new institution would be strictly limited by Congress to reforming the root causes of the paradigm paralysis afflicting our nation’s healthcare industry. NATIONAL HEALTH would not mediate any direct financial disbursement for health spending. The Federal expense for the new institution would have represented a 0.03% increase for our nation’s Federal health spending of $3.8 Trillion during 2019.
FIRST & FOREMOST: FINANCIAL STABILITY
We propose that the absence of one tradition adversely affects all the other traditions of our nation’s healthcare. As of 2020, the United Nations defines 66 of its nations as advanced/developed. Unlike the other 65 advanced/developed nations, our nation’s healthcare industry does not have the means to assure that Primary Healthcare is a priority for each of our resident persons. Chief among many problems, our nation’s Primary Healthcare has become neither equitably available to nor culturally and ecologically accessible by each resident person of every community. This deficiency has contributed substantially to the fundamental, overriding problem of our nation’s healthcare: its very high cost. In 2019, our nation’s health spending was at least 27% more within our national economy than for the economy of any other developed nation of the world. For 2019, the excess health spending represented $1.0 trillion, of which the Federal government paid 45% or $453 billion. The world’s advanced-developed nations that devote a substantial investment in Primary Healthcare for their citizens also have a much lower portion of their national economy devoted to total healthcare spending, as in Australia at 11%. The other advanced-developed nations in 2019 allocated 13% or less of their national economy to health spending. For the USA in 2019, it was 18.0%.
The World Health Organization (WHO) formulated its definition for a nation’s Primary Healthcare in 1975. The WHO definition became the reference point in 1975 for the “Primary Health Care” definitions proposed subsequently, including th new definition formulated specifically for the NATIONAL HEALTH Proposal. The GLOSSARY for HEALTHCARE Sub-Page of the APPENDIX Page includes a word-for-word quotation of the WHO definition. The WHO definition for Primary Healthcare describes it as having broadly available and accessible attributes. Solving this national deficiency within every community will be essential for the success of any proposal for fundamental healthcare reform.
On the NATIONAL HEALTH Page and its Sub-Pages, I describe a set of Operational Tasks as the basis to establish the new, Federally chartered, semi-autonomous institution with a mandate to coordinate the dimensions required to progressively form a new, comprehensive strategy for improving our nation’s Population Health as well as its Primary Healthcare. These Global Tasks would begin by promoting 1) the community-originated leadership to assure that ^ enhanced Primary Healthcare becomes equitably available as well as ecologically and culturally accessible by each resident person within their own community and that ^ this Primary Healthcare occurs in collaboration with their adjacent communities’ parallel commitments to reduce their locally unique social adversities AND 2) four national projects to support the local sponsorship of enhanced Primary Healthcare, community by community.
NATIONAL HEALTH — Starting with a New Strategy and Four National Projects
To reform our nation’s healthcare, the NATIONAL HEALTH Page and its 5 Sub-Pages describe the Global Tasks required to achieve its ‘VISION’, MISSION, and PRINCIPLES. The new institution would be chartered by an Act of Congress and subsequently affirmed by each State’s legislature. As a semi-autonomous institution, its decentralized governance would establish a strong community, regional, and national leadership connection. This new institution would have a Congressional mandate to implement the New strategy and Four National Projects.
Most importantly, the New Strategy would promote the formation of locally established, collaborative CommunityHealthforums, viz., Forums, for nearly 810 separate, contiguously related, and county-defined population units, each encompassing between 100,000 & 600,000 resident persons. Each State would initially be assigned the number and general boundaries of the Forums to be established based on their respective State’s total population, viz., nationally on average of 1 Forum per 400,000 resident persons. The initial GOVERNANCE Sub-Page of the GOALs Page described a possible allocation. Secondly, the new strategy would recognize Altruism, Trust, Cooperation, Reciprocity, and Excellence as the guiding PRINCIPLES for the governance of NATIONAL HEALTH. The PRINCIPLES would apply as well to the affairs of its nine Regional Councils and their 810 CommunityHEALTHforums.
The overall leadership process would evolve through a consultative relationship between the Board of Trustees and its 9 Regional Councils. Each Regional Council would offer Technical Assistance to their Forms totaling 90. Also, each State would be assisted by their associated Regional Council to promote a local meso-social network to promote the founding of their Forums. Generally, each Forum would be ultimately responsible for promoting its own affairs, including its own local sources of budgeted funding. A minimally nested, span of control would intentionally promote a very wide variety of Forums, some that are barely viewable as functional. By requiring contact with a variety of Forums and a contiguous interaction with their neighboring Forums, the model would intentionally tolerate various levels of chaos that will occur initially. Without any legally defined institutional control, a COMPLEX ADAPTIVE SYSTEM would become the model for managing the national affairs for reconfiguring our nation’s Population Health and its Primary Healthcare by the Board of Trustees of NATIONAL HEALTH.
Each Forum would begin by promoting local solutions through collective action for ensuring that enhanced Primary Healthcare becomes progressively available to and accessible by each of their community’s resident persons. The success of their efforts would be monitored locally by measuring the total number of hospital days required monthly or weekly by their community’s resident persons, as duplicated by each Forum nationally for a total of nearly 810 communities.
FOUR NATIONAL PROJECTS
NATIONAL HEALTH would also have a Congressional mandate to carry out Four National Projects to support the local improvement of Primary Healthcare for each resident person, community by community. Promoting the needs of each community for their enhanced Primary Healthcare will be difficult. Without a nationally defined focus on the importance of Basic Healthcare Needs, equitably available and enhanced Primary Healthcare will not be feasible as the crucial capstone for improving the entire spectrum of healthcare. As mandated by its Congressional Charter, the NATIONAL HEALTH Proposal would establish and sustain Four National Projects. They are as follows:
– – – PRIMARY HEALTHCARE BENEFITS PLAN – – –
The PRIMARY HEALTHCARE BENEFITS PLAN (PHBP) would standardize the basic definitions and structure of the healthcare benefits eligible for reimbursement by any third-party insurance or another source of financial support for the Basic Healthcare Needs of each resident person during their lifelong survival. The PHBP may require up to 4 years to be fully defined as it incorporates the recognition of National, regional, State, County, and community needs. The actual payments would still be left to the reimbursement institutions or other means of financial support that are currently established. The PHBP would also include 1) standard provisions for defining health services not eligible for reimbursement or its financial support in connection with the BHBP and 2) a reporting system to monitor the augmented reimbursement for the health care provided by a Primary Healthcare clinic that is HEALTH Security certified.
The BHBP would apply to all sources of economic resources that support any resident person’s Primary Healthcare as a means to promote seamless Primary Healthcare for every resident person during their survival. For a view of this scenario, these economic resources include: each resident person, private health insurance, Medicaid, Medicare, Federal and State Public institutions (Active Military, Retired Military, Veterans Administration, Community Health Centers, Alaskan and Native American Health Services, Correctional Facilities, Mental / Developmental Facilities, Ambulatory Health Servies embedded within Governmental facilities, Universities, and Colleges), philanthropy, and third-party liability. The PHBP will operationally be required to participate in the HRMP National Project described below.
– – – PRIMARY PHYSICIAN EDUCATION PLAN – – –
The PRIMARY PHYSICIAN EDUCATION PLAN ( PPEP ) would represent a progressively evolving consensus among our nation’s medical schools as sponsored and affirmed by NATIONAL HEALTH. The PPEP would describe the general provisions for the pre-medical, undergraduate medical, post-graduate, and subsequent career medical education for Primary Physicians necessary to support the PRIMARY HEALTHCARE BENEFITS PLAN for all resident persons. The PPEP would also establish a national continuing education process for all Primary Physicians, nurse practitioners, and physician assistants who are associated with HEALTH SECURITY certified Primary Healthcare. This nationally structured continuing education process would evolve as a result of the regional, medical schools’ connection with their Region Council and its 90 Forums.
– – – HEALTH SECURITY CERTIFICATION PLAN – – –
The HEALTH SECURITY CERTIFICATION PLAN ( HSCP ) would assign its monitoring responsibility to each Regional Council and eventually to one of each Forum’s contiguous Forums. To implement the HSCP, each Regional Council would be guided by the priorities established by the authority assigned to it by the Board of Trustees. As a ‘rule of thumb,’ each Regional Council would eventually be responsible for the certification of approximately 9-12 thousand Primary Healthcare clinics with the combined capability of offering enhanced Primary Healthcare to approximately 36 million resident persons. Each Regional Council would likely form its own strategy for implementing these responsibilities in association with certain selected, mature Forums.
Any Primary Healthcare clinic achieving HEALTH SECURITY certification would be eligible for augmented reimbursement, initially a supplemental capitation in addition to fee-for-service. The extra financial reimbursement would be necessary to support the 24/7 level of telephonic medical TRIAGE that would be required to achieve certification. An advanced level of Medical TRIAGE would require BSN level nurses during clinic hours and a clinic’s physician after hours. In addition, the certification would require each clinic’s physicians and extended practice personnel (nurse practitioners or physician assistants) to participate in a continuing education plan sponsored by one medical school or a group of medical schools within their Region. Finally, each clinic would manage its own strategy to sponsor each licensed employee’s Career Formation Accord.
– – – HEALTH SPENDING RISK-MANAGEMENT MONITORING PLAN – – –
The HEALTH SPENDING RISK-MANAGEMENT MONITORING PLAN may be the most difficult to conceptualize and implement. Applicable consultative experience would need to design a selected mirroring, financial reporting format by the current financial systems that economically sustain Primary Healthcare. Historically, these financial reports were produced by the mature Health Maintenance Organizations that existed from 1985-1995 to capitate Primary Healthcare, coordinate benefits, manage stop-loss protected risk-pools, and responsively manage prior-authorization processes. Successfully implementing this strategy initially as mainly a monitoring process would then precede any transition to an actual, deeply nested, health spen administration problems to any community by community priority for improving our nation’s Social Cohesion.
Remember that in 2019, health spending represented 18% of our GDP. During that year, most of the other advanced-developed nations experienced national health spending that was 13% or less of their GDP. For 2019, the difference for our economy between 13% and 18% represented $1.08 TRILLION, for which the Federal Government paid 45% in cash. The $450 Billion was nearly equal to our Federal deficit for that year.
ALTOGETHER NOW
Promoted by the New Strategy and the Four National Projects, adequately financed and certified Primary Healthcare would represent the foundation for the occurrence of justly efficient and dependably effective healthcare for the Basic and Complex Healthcare Needs of every resident person. Slowly but surely, our nation’s healthcare industry would eliminate the pervasive gaps in quality between one community and another as well as among all of the States. Importantly, the overall improvement would be nationally recognized as being fostered by equitable available, enhanced Primary Healthcare and by the improvement of each community’s Population HEALTH by their Forum and its connection with NATIONAL HEALTH.
PRIMARY HEALTHCARE
As within the definitions for HEALTH and FAMILY, each person’s lifelong Well-Being requires the presence of and continuing connection of CARING RELATIONSHIPs with their Healthcare Team that serves their Basic Healthcare Needs. Its definition represents the sentinel definition within the DESIGN EPISTEMOLOGY comprising 29 other concepts, as defined within the RATIONALE Sub-Page of the OVERALL Page.
CARING RELATIONSHIP may be defined as
^
a dyadic social interaction involving diverse scenarios that
begins with each person’s respect for the other person’s autonomy,
thrives when each person steadily renews their adaptive skills, and
flourishes when the two persons communicate ‘in harmony’ with
warmth, non-critical acceptance, honesty, and empathy.
For NATIONAL HEALTH, Primary Healthcare can be understood most easily as having two fundamental functions.
- First, Primary Healthcare should offer the health care necessary for a person’s Basic Healthcare Needs, especially by an enhanced level of 24/7 medical TRIAGE. The GLOSSARY for HEALTHCARE Sub-Page of the APPENDIX Page offers an expanded definition for these Basic Healthcare Needs.
- Second, Primary Healthcare should represent an evolving, Caring Relationship between each resident person and their Primary Physician. This relationship then becomes the basis for *) coordinating the health care of any Complex Healthcare Needs with the person’s Basic Healthcare Needs and for *) clarifying the person’s goals for the healthcare of these Complex Healthcare Needs. Investing in the “trustworthiness” of this relationship, over time, is especially important for any resident person whose healthcare for Basic Healthcare Needs eventually requires integration with Complex Healthcare Needs.
It is likely that our nation’s progressively worsening maternal mortality ratio will not begin to improve until a trusting relationship with a Primary Physician exists well before any pregnancy occurs. This trusting relationship and its availability and accessibility then becomes transferable and subsequently more easily maintained during any maternal healthcare. More importantly, the reduction of maternal mortality will also require a nationwide improvement of every community’s social cohesion. Additionally, this nationally enhanced social cohesion would promote a generational reduction of child maltreatment, childhood obesity, adolescent suicide/homicide, substance abuse/mortality, homelessness, mass shootings, and mid-life depression/disability.
Beginning with Family Medicine specialists, a Primary Physician would also include general Pediatric and general/geriatric Internal Medicine Specialists. For highly complicated health conditions such as cystic fibrosis or multiple-system coexisting degenerative HEALTH conditions, another physician specialist might be temporarily defined as a Primary Physician for a resident person. Each Primary Physician and their Health Care Team would offer a continuum-of-care level of healthcare rather than just a physician to call whenever a new HEALTH Condition has just occurred. Each Primary Physician’s, Health Care Team would likely include either a Physician Assistant or Nurse Practitioner.
Eventually, the role of each Primary Physician must evolve over time for the benefit of each resident person. This health care should require a resilient and widely supported professional recognition of a Primary Physician as having the responsibility for a resident person’s Basic Healthcare Needs and the coordination of this health care with any concurrent Complex Healthcare Needs. The importance of these skills is especially prominent for 18 out of every 100 resident persons who, as a group have highly complex health problems, accounting for 82% of our nation’s health spending for healthcare in 2017. (MEPS 2017)
A NEW STRATEGY FOR POPULATION HEALTH
A nationally supported and sanctioned new strategy for the advancement of Primary Healthcare will indirectly promote improvement at all other levels of our nation’s healthcare. In effect, the new strategy offers a clearly definable process of connecting the CommunityHEALTHformums with the institutional renewal of our nation’s entire healthcare. This renewal would form the basis for controlling our nation’s health spending and eliminating the gaps of effectiveness within our nation’s healthcare. Improving its low efficiency and variable effectiveness will be vital for our nation’s future as we encounter a changing level of uncertainty occurring within the worldwide community. The process of healthcare reform must be accompanied by a nationwide improvement of social cohesion as driven by the persistently reciprocal contributions of social capital by neighboring communities for each other’s Survival Commons. The simultaneously promoted formation of a CommunityHEALTHforum within every resident person’s community will also be the force to download the leaking-boat problems associated with our nation’s Population HEALTH.
Whether or not the NATIONAL HEALTH Proposal becomes a model for the reform of our nation’s healthcare industry, an unprecedented level of change will eventually be required by our nation’s healthcare industry. The NATIONAL HEALTH Page and its Sub-Pages describe an institution that would promote healthcare reform that is intentionally focused on every community’s needs. Each CommunityHEALTHforum (Forum) would be formed by local initiative including any requirements for its administrative support, each involving approximately 400,000 resident persons. NATIONAL HEALTH would define the process for the properly constituted formation of these volunteer efforts and authorize support in the form of technical assistance with a national connection among all of the 810 Forums. The initial and continuing recognition of each Forum would occur based on a policy initially established by the Board of Trustees and subsequently adapted by its Regional Councils. These Operational Statements would require an annual assessment of Unstable HEALTH, community by community. This assessment would lead to the annual revision of each Forum’s Community HEALTH Plan as the basis for steadily improving the Stable HEALTH experienced by their respective community’s resident persons, neighborhood by neighborhood.
These Community HEALTH Plans would assess the equitable availability of Primary Healthcare and its HEALTH SECURITY certification status. Each annually updated edition of a Community HEALTH Plan would also describe the progress of community-originated collective action projects in place for resolving the deficits associated with the other community attributes adversely influencing the occurrence of Unstable HEALTH within its neighborhoods, e.g., poverty, social mobility, and social isolation. Each Community HEALTH Plan would also include an annually updated MASTER DISASTER MITIGATION PLAN for its predictable disasters as the basis for managing the occurrence of any unpredictable disasters.
REGULATORY CONTROL
Even though there would be an annual review by Congress and the President, NATIONAL HEALTH would represent a new, semi-autonomous level of regulatory control. Its formation, as well as any other comprehensive proposal for healthcare reform, requires an understanding of the legal, medical, social, economic, and innovation traditions as the basis to subsequently add any new level of regulatory control. Beginning with an attempt to understand our nation’s long-term healthcare trends, the TRADITIONS Page and its Sub-Pages describe, one view of the root causes underlying the paradigm paralysis afflicting our nation’s healthcare industry. The suggested regulatory processes undertaken by NATIONAL HEALTH reflect this analysis.
The research of Professor Elinor Ostrom supports the structure of this new strategy: its decentralized governance. The national debate surrounding any new level of regulatory oversight for healthcare should represent only one unifying question: how can our nation successfully promote the equitably available, ecologically and culturally accessible, justly efficient, and dependably effective enhanced Primary Healthcare for every resident person, community by community? The new regulatory controls that NATIONAL HEALTH would promote the direct involvement by each of the affected healthcare institutions in their own self-regulation. The overriding purpose for the new regulatory controls is our nation’s need to promote a nationally shared understanding regarding the Knowledge, Resources, and Human Dignity required to improve the Well-Being of every resident person, neighborhood by neighborhood and community by community.
– – – – – – – – – – – – CLOSING COMMENTARY – – – – – – – – – – – –
above all else EQUITABLY AVAILABLE
During any person’s lifetime, many resident persons of the United States will have endured extended intervals of time without health insurance benefits or without a Primary Physician. Increasingly, many persons will also have endured Unstable HEALTH without both health insurance benefits and a Primary Physician. Putting aside the issue of universal health insurance, any person who does not have an established Primary Physician would have difficulty obtaining health care that is both efficient and effective for a rapidly worsening, new HEALTH Condition. This is an especially dangerous situation for a resident person with known Unstable HEALTH as in diabetes, emphysema, or cancer. For infants, the disabled, the homeless, and women during a pregnancy, the risk of an Unstable HEALTH complication for a person without an established Primary Physician can be much worse.
Primary Healthcare for each resident person should represent a relationship with a Primary Physician that began before any new HEALTH Condition appears, especially for maternal health. Clearly, universal health insurance is a very close second as a need for any new HEALTH Condition. But, with or without universal health insurance, our nation’s healthcare is unlikely to become either fully efficient or even broadly effective without enhanced Primary Healthcare that is equitably available to as well as ecologically & culturally accessible by each resident person.
The most important attribute of enhanced Primary Healthcare is its responsiveness to an unexpected worsening of a person’s HEALTH, especially if the person makes even the smallest effort to access the medical TRIAGE offered by their Primary Healthcare Clinic. The success of this process over time depends on the anticipatory effort to promote a caring relationship with a Primary Physician. This is the basis for the health care of any rapidly progressive health condition for which timeliness is directly related to the success of restoring a resident person’s Stable HEALTH and the opportunity to optimize the resources necessary to re-establish the resident person’s Stable HEALTH. The healthcare inadequacies represented by too many resident persons without enhanced Primary Healthcare represent the fundamental barrier requiring resolution for achieving healthcare that is optimally efficient and effective for our nation’s resident persons, especially when compared to the other advanced/developed nations of the world. Our nation already produces more food with the resources applied than any other nation, by a wide margin. The same reality should characterize our nation’s healthcare.
CONGRESSIONAL CHARTER
To direct the reform of our nation’s healthcare industry, the Congressional Charter would mandate that NATIONAL HEALTH achieve a reduction in the portion of our nation’s economy devoted to healthcare. Ten years after the initial Meeting of its Board of Trustees, the cost of our nation’s healthcare should represent a much smaller proportion of our nation’s gross domestic product. Most importantly, a reduction in our nation’s health spending for healthcare would represent a major improvement in our ability to augment each community’s Survival Commons and to sustain our nation’s autonomy within the worldwide community, especially its marketplace arenas for the world’s Resources, Knowledge, and Human Dignity.
The new strategy for improving Primary Healthcare will depend on the extent to which the Congressional Charter for NATIONAL HEALTH becomes actively and widely supported. This support must come from within every community as well as from the regional and national institutions responsible for sustaining the healthcare industry. Among these institutions, a few will likely continue their own Vision, Mission, and Values based on the historic traditions of our nation’s healthcare. Possibly, an isolated institution will continue its Mission unchanged and actively resist any change. To honor its charter, NATIONAL HEALTH would acknowledge the difficulties associated with remodeling the current paradigm of our nation’s healthcare. In spite of these difficulties, the new strategy will engage all institutions within the healthcare industry based on the NATIONAL HEALTH PRINCIPLES. To promote a positive and adaptive reform process, the Board of Trustees and its nine Regional Councils will have the responsibility to jointly define the details of implementing the new strategy. Altruism, Trust, Cooperation, Reciprocity, and Excellence will represent the PRINCIPLES for guiding this implementation process.
NATIONAL HEALTH will maintain a Strategic Projects Plan and annually report an evaluation of its status to the President and Congress. The annual report will describe the progress achieved by the last Strategic Projects Plan and also any continuing traditions resisting this progress. It is possible that a few healthcare institutions will be especially resistant to the new strategy and its three national projects. As a last resort and in spite of positive, sustained efforts to engage this resistance by NATIONAL HEALTH, special Congressional legislation may be necessary as a means to eventually achieve a uniform, wide-spread, and continuing support for the reform of our nation’s healthcare industry. Only in special circumstances of institutional resistance for which there is widespread support for Congressional action should this be requested by NATIONAL HEALTH. Once confronted by a widespread consensus persistently maintained, it is unlikely that Congressional intervention would ever be required. A connection with the heritage of Martin Luther King, Jr. might be needed. The quotation from The Reverend Doctor King cited above would apply. Our Nation’s commitment to the rule of law as the basis for governmental sovereignty should be the permanent gold standard for the affairs of NATIONAL HEALTH.
the FIRST GOAL
The Congressional Charter would define the initial GOALs for NATIONAL HEALTH. As a means to support our national budget as well as our nation’s financial autonomy within the worldwide economy, I propose that the Charter cite three very specific long-term GOALs for NATIONAL HEALTH. As a measure of improved efficiency, I propose a substantial reduction of our nation’s health spending as a portion of our nation’s Gross Domestic Product. Even including the cost of universal health insurance, I propose that health spending for our nation’s healthcare should eventually represent no more than 13.0%, ideally 11%, of the Gross Domestic Product. In 2019, it was 18.0%. Since the other advanced/developed nations of the world spend on average less than 13.0% of their gross domestic product on healthcare, a GOAL of 13.0% should be attainable with a widely supported commitment to the new strategy and four national projects. Our Population HEALTH and its healthcare industry have the potential to become clearly the best in the world. But, as compared to 1969, there is a certain life-threatening health condition that still affects too many families and their Family Convoy.
the SECOND GOAL
The NATIONAL HEALTH Proposal reflects an awareness of at least one life-threatening health condition requiring immediate attention: women who die in association with a pregnancy. According to the World Health Organization, the maternal mortality ratio in 2015 for our nation’s women ranked 42nd worst among the 51 advanced developed countries of the world. Even more alarming is the change in the maternal mortality ratio between 1990 and 2015. It worsened by 21%, the only advanced developed nation with a worsening maternal mortality ratio. Currently, there are many community, regional, and national efforts that focus on promoting reliably effective, maternal healthcare. It is likely that chronic stress associated with poverty, poor housing, food insecurity, adolescent health, neighborhood violence, and substance abuse combine to disturb the stability of maternal health for a large portion of our nation’s resident persons, especially for women during a pregnancy.
As sponsored by enhanced Primary Healthcare for every resident person, a renewed tradition of equitably available along with ecologically and culturally accessible healthcare for Primary Healthcare should be the most important step for stabilizing the HEALTH and its healthcare for any woman who is or may become pregnant. The state of Massachusetts should receive a national Prize. From 1986 through 2019, they maintained a maternal mortality ratio within the best cluster of states for all six separately sequential, state by state, and prolonged-interval maternal-mortality data sets. The most recent national data set was reported for 2019.
With focused Congressional action, NATIONAL HEALTH could soon augment the current efforts for improving maternal health. 2023 is the year to begin improving the health care for any resident person with Complex Healthcare Needs, especially for women during a pregnancy. Along with the first GOAL, a 70% reduction in our nation’s maternal mortality ratio would represent the second GOAL. By 2033, our nation’s mothers deserve no less. Within 6 months after its authorization, NATIONAL HEALTH could be a reality for improving the Stable HEALTH of our nation’s mothers and their Families.
the THIRD GOAL
Since 1969, the traditions of the healthcare industry have achieved many highly skilled improvements for the Complex Healthcare Needs of each resident person. Sadly, the traditions of our nation’s healthcare have not promoted the uniform improvements necessary for the Basic Healthcare Needs of each resident person. Created by its paradigm paralysis, the result of this disparity represents a “Tragedy of the Commons” involving the annual health spending for our nation’s healthcare. This Blog represents a view that the ideas, commitments, and relationships necessary to resolve the current paradigm paralysis already exist at all levels of our nation’s healthcare industry, especially within every community. Integrating the depth and breadth of the Four National Projects and the New Strategy into the institutional fabric of each community’s healthcare institutions will require a heroic commitment. The framers of our nation’s Constitution and the leaders of our nation’s WWII effort shared the same heroic commitment. No less than Congress and every State legislature must honor this level of commitment to the NATIONAL HEALTH Proposal.
The Third GOAL for measuring the success of NATIONAL HEALTH may be the most difficult. Briefly stated, each State legislature must authorize the presence and authority of NATIONAL HEALTH for improving the healthcare of their state’s resident persons. To most clearly focus the third GOAL, I propose that each State should authorize the requirements of their own State’s healthcare institutions, at all scales, to participate fully in the affairs of NATIONAL HEALTH within 3 years after the initial MEETING of the NATIONAL HEALTH Board of Trustees.
COMMUNITY BY COMMUNITY
What our nation’s Population Health and its Healthcare needs is NATIONAL HEALTH, a new nationally sanctioned, semi-autonomous institution to sponsor the reform it desperately needs, community by community. The New Strategy and Four National Projects should refocus the community-based social capital commitments and relationships that already exist as a basis to achieve enhanced Primary Healthcare for each community’s resident persons. The Design Principles for managing a Common-Pool Resource, as defined by Professor Elinor Ostrom, await our nation’s resolve to act.
During 2017, the United Nations projected that the world’s population will increase from 7 billion in 2011 to 9 billion in 2050. With a high level of uncertainty associated with this population change, we cannot ignore the unforeseeable challenges to the autonomy of our nation that could affect our nation’s future stability, as in the pandemic onset during 2020. Fundamental healthcare reform for the current HEALTH of every resident person is a requirement for assuring the stability of our nation’s future autonomy within the worldwide community. Our nation has a heritage of forging heroic commitments for the Survival Commons of each community’s resident persons, beginning with the Declaration of Independence in 1776 and, more recently, with our nation’s heroic commitment to World War II after the Pearl Harbor attack in 1942. I propose that we renew this heritage once again by adopting the NATIONAL HEALTH Proposal to improve the Well-Being of every resident person.
Truly, a historic commitment will be necessary to improve our nation’s health for our resident persons encumbered by social adversity, especially when associated with a woman’s maternal commitment.
S U B P A G E S
WELL-BEING
This word has a conceptual heritage of at least 2,500 years. The basis for its inclusion in a contemporary definition of HEALTH is unlikely to be especially surprising, especially given its widespread use. Its context for NATIONAL HEALTH receives a thoughtful description.
DISRUPTIVE PROCESS
The definition of HEALTH for this Blog defines the lifelong occurrence of the processes necessary for assuring a person’s Well-Being when encountering certain disturbances that degrade the experience of this Well-Being. The uniquely occurring disturbances that degrade a person’s resilience involve the complex interaction of Cosmological, Biological, and Human Dignity phenomena. Given the full definition of HEALTH as associated with NATIONAL HEALTH, it is possible to anticipate how complicated the reduced resiliency underlying a resident person’s Unstable HEALTH, viz., its Diseases, can become.
AVAILABLE & ACCESSIBLE
These two QUALITY attributes of healthcare occur frequently within any reference to healthcare reform. This Sub-Page is intended to reveal how these two terms may be used to clarify alternate attributes for its acceptability. One attribute, availability, pertains to the perceptions applied to a person’s travel to a source of health care. The other attribute, accessibility, pertains to the capabilities of the source of health care to actually be reliably responsive and helpful given the challenges associated with managing its availability. These both have multiple dimensions as reviewed by this Sub-Page.
GLOBAL TASKS
To convert concepts for healthcare reform to institutional performance, the dimensions of institutional performance will require a high level of precision. This applies especially to a highly de-centralized institution that spans 50 states (including Protectorates) and applies to 330 million resident persons. This commitment reflects a priority that success will ultimately be associated with the social capital accruing among the relationships and responsibilities required for its implementation. With 90 Members (Trustees and Councils), 200 Associates (employees) and 7,290 Advocates (810 CommunityHEALTHforums), every possible means to avoid cognitive dissonance will be required. The Global Tasks establish the outline for establishing the Policy and Procedure OPERATIONAL STATEMENTS for NATIONAL HEALTH. They are: ORGANIZE GOVERNANCE, PURSUE ‘VISION’, BUILD COMMUNITY, MANAGE RESOURCES, and DEVELOP SKILLS. It is likely that the traditions established by Stephen B. Covey should be engaged to prioritise this endeavor, given his career-long study of this phenomenon. (Covey 2002)
“PARKINSON’S LAW”
This is the title of a small book written by C. Northcote Parkinson and first published in 1957. The book is best described on the inside of its cover page for the 1964 edition. It says: “Everyone has heard of Parkinson’s Law — but how many can say what it means? For those who can’t, this book is a devastatingly accurate description of how administration really works in government, business, and every human group.” A bit of hyperbole, you say. ‘Maybe and maybe not’, say I.
This page has the following sub pages.