enhanced Primary Healthcare
EXECUTIVE SUMMARY
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 )
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 apply as a means to predict the likely success for the management of a finite resource that is variably accessible for 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: the fresh-water aquifer underlying the city of Los Angeles.
Soon after 1930, a locally initiated and community-supported collaboration began among the county governments involving the 5 separate counties associated with the city of Los Angeles. 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 water-users achieved a goal of limiting the use of the aquifer. These agreements also arranged to invest locally originating economic resources to construct access to outside water sources 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 various 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 annual, health spending increase as a portion of our nation’s economy (GDP).
I am especially influenced by her studies that defined the Design Principles for managing a common-pool resource. These Design Principles assess the likely success of any strategy associated with the successful management of a common-pool resource. Most importantly, she identified the performance of voluntary institutions as having greater success for preserving a commons as compared to the actions of an authoritarian, centralized 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.
Viewing the steadily worsening level of worldwide social and economic turmoil, our nation’s healthcare industry now requires a precisely defined new strategy to achieve a substantially improved level of efficiency and effectiveness. The application of known and well-defined realms of Knowledge, new to healthcare, must now be mobilized to achieve Stable HEALTH For Each Resident Person. This Blog describes one possible means to this end.
For this Blog, collective action and the extensive research for its use in managing a commons represents the operational tasks for the new strategy 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 as a means to release the paradigm paralysis characterizing the efficiency and effectiveness of our nation’s healthcare industry as in our nation’s population HEALTH
Referring to the quotation above as formulated by Professor Ostrom, the total number of hospital days used monthly by the resident persons of a community would represent the most succinct, initial tool for monitoring the adequacy of its community’s social capital asset, its Survival Commons. Nearly 800 communities, each serving the needs, on average, of approximately 400,000 resident persons, would use collective action to define their own Community HEALTH Plan. Altogether, 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 concept for healthcare reform, there is some value in understanding the complexities that underlie a person’s perception of Stable HEALTH. Proposing a new definition for HEALTH is very complicated given the wide range of contributing factors, especially genetics as well as epigenetics. The use of “temperament” may be new to many. 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 (i.e., sentient reflective-Cognition) capability.
Finally, the relationship between a community’s social capital, its Survival Commons, 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. Eventually, the persistent exchange of social capital contributions between neighboring communities becomes the basis for improving a nation’s social cohesion among its states.
HEALTHCARE TRADITIONS: A NEW ERA
HEALTH may be defined as
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a person’s daily experience of Well-Being during their lifelong survival that is
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A. Endowed by the gestational formation of sufficient synergy between
the person’s innate temperament and the person’s underlying baseline homeostasis
for modulating the person’s initial adaptive resilience
immediately after birth and subsequently during early childhood;
^
B. Nurtured by the person’s caring relationships that originate before birth
from within the person’s Family to encourage the person’s search
for the broadest portrayal of their sentient reflective-Cognition
Cluster of Human Capabilities as a joyful dependent person and originate after birth
from within the person’s Family, its Extended Family, and its micro-social networks
to mentor the adaptive resilience of the person’s innate temperament during
the social interactions occurring while becoming a courageous independent person;
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C. Challenged by the person’s daily encounters with modest disruptive processes
beginning before birth and occurring as interacting combinations and patterns
to cause variably reversible and either beneficent or maleficent effects
on the adaptive resilience of the person’s combined innate temperament and
sentient reflective-Cognition Cluster of Human Capabilities as ameliorated lifelong
by the joyful and courageous caring relationships originating from within
the person’s Family, its Extended Family, and its micro-social networks;
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D. Matured by the person’s episodic encounters with substantial disruptive processes
beginning before birth and occurring as interacting combinations and patterns
to cause variably irreversible and usually maleficent effects on the resilience
of the person’s combined Clusters of Human Capabilities and innate temperament
as variably prevented, mitigated, and ameliorated lifelong
by the Personal Survival Plan of the person; AND
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E. Sustained by the person’s hopeful caring relationships,
the Family Traditions of the person’s Family, and
the Survival Commons of the person’s community
until the resilience of the person’s combined
Clusters of Human Capabilities and innate temperament
becomes insufficient for the person’s survival
from their lifelong encounters with disruptive processes.
Before 1969, a stomach ulcer, heart attack, or measles eventually afflicted at least someone within the Family and Extended Family of almost every resident person. Fifty-one years ago, 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 (25). 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 HEALTH and its 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 for preventing infection had led to the initial evolution of hospitals as a place for this surgery and its related healthcare, as we now know it. In effect, the occurrence of health care primarily by a person’s Family and Extended Family at home, has progressively become replaced by another location as offered by strangers. It is possible that the care of each person at home was associated with an improved level of over-all connection among the members of a person’s Family and Extended Family subsequently during recovery.
In effect, the traditions related to the evolution of hospital-based healthcare actually diminished the overall role of the Family and Extended Family for the healthcare needs of each person and its importance for maintaining a person’s Family Traditions. Eventually, the importance of each person’s Family became adversely affected by certain other ecologic factors such as the decline of neighborhood social networks, decreasing participation in the non-profit institutions of each community’s municipal life, women’s employment, pockets of entrenched poverty, homelessness, and addiction.
Certainly, there is a 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 (ACA), lingering disagreement still exists 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 and Extended Family must be included within our nation’s health care traditions.
Increasingly, our healthcare industry has needed a new strategy to redirect its traditions as a basis for serving the Basic Healthcare Needs as well as the Complex Healthcare Needs of each resident person. This new strategy is especially necessary since healthcare for many resident persons has become increasingly complicated since 1969. This 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 and ecologically accessible by the resident persons within each community.
Our nation needs a new, nationally sanctioned institution with strong community connections to promote the reforms necessary to release the untapped excellence of our nation’s healthcare. Most importantly, this new institution should sponsor its reform strategy primarily for the benefit of each person’s HEALTH, community by community. Lacking this institution, our healthcare industry will continue to suffer from the effects of the paradigm shift (20) 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 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 is especially necessary to assure the future adaptability as well as the immediate reform of our nation’s healthcare industry. This Blog describes a clearly defined and precisely focused concept for a new semi-autonomous institution, NATIONAL HEALTH, chartered by Congress with a mandate to foster a continuously self-reforming healthcare industry.
To limit the scope of NATIONAL HEALTH, 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 total health spending during 2019 of $1.674 Trillion.
We propose that the absence of one tradition adversely affects all the other traditions of our nation’s healthcare. As of 2015, the United Nations defines 51 of its nations as advanced/developed. Unlike the other 50 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 ecologically accessible by too many of each community’s resident persons.
This deficiency has caused one fundamental, over-riding problem with our nation’s healthcare: its very high cost. In 2016, our nation’s health spending was at least 38% more within our nation’s economy than for the economy of any other developed nation of the world. For 2018, the excess health spending represented $1.05 trillion, of which the Federal government paid 47% or $493 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%. Most of the developed nations in 2018 allocated 12-13% or less of their national economy to health spending. For the USA in 2018, it was 17.8%.
The World Health Organization (WHO) formulated its definition for a nation’s Primary Healthcare in 1975. The WHO definition became the reference point for the “Primary Health Care” definitions subsequently proposed since 1975, including this Blog’s definition formulated specifically for NATIONAL HEALTH. The GLOSSARY for HEALTHCARE Sub-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 Initiative Page and its Sub-Pages, I describe a set of Global Tasks as the basis for promoting a new institution with a mandate to collaborate our nation’s long-term strategy for healthcare reform. These Global Tasks would promote 1) community-driven leadership to assure that enhanced Primary Healthcare is equitably available by each resident person within their community along with a collaboration with adjacent communities to contribute Social Capital to each other’s evolving Survival Commons and 2) three national projects to support the local sponsorship of enhanced Primary Healthcare, community by community.
NATIONAL HEALTH
To reform our nation’s healthcare, the Initiative Page and its Sub-Pages describe the Global Tasks required by NATIONAL HEALTH to achieve its V I S I O N, 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 a new strategy.
Most importantly, this new strategy would promote the formation of locally collaborative Community Health Forums for nearly 800 separate, contiguous county-defined population units encompassing @100,000-400,000 resident persons. Each Forum’s total population basically related to its population density. Secondly, the new strategy would recognize Altruism, Trust, Cooperation, Reciprocity, and Excellence as the guiding PRINCIPLES for the governance of NATIONAL HEALTH. These PRINCIPLES would apply to the affairs of its nine Regional Councils, their eighty-one District Coalitions, and the ~800 Community HEALTH Forums.
The over-all leadership process would evolve through a consultative relationship between the Board of Trustees and its 9 Regional Councils. Each Regional Council would supervise the functions of 9 District Councils for a total of 81. Each District Coalition would be especially crucial as they monitor and support the properly constituted formation of 9 or more Community Health Forums to promote local community needs for enhanced Primary Healthcare by the involvement of their community’s local stakeholders.
Each Forum would initially promote local solutions through collective action for ensuring that enhanced Primary Healthcare is eventually equitably available to and ecologically accessible by each of their community’s citizens. The success of their efforts would be monitored initially by measuring the total number of hospital days required monthly by their resident person population, as duplicated by each Forum nationally for a total of nearly 800.
NATIONAL HEALTH would also have a Congressional mandate to carry out three national projects to support the local improvement of Primary Healthcare for each resident person. Promoting the needs of each community for its equitably available Primary Healthcare will not be possible without a nationally defined focus on the importance of Basic Healthcare Needs as the crucial “stepping stone,” the capstone, for improving the entire spectrum of healthcare. Mandated by a Congressional Charter, NATIONAL HEALTH would establish and sustain Three National Projects. They are as follows:
- a PRIMARY HEALTHCARE BENEFITS PLAN to define the minimum benefits to be covered uniformly by all economic resources as the basis for the reimbursement of or financial support for each resident person’s Primary Healthcare ( NOTE: The essential economic resources include: each resident person, private health insurance, Medicaid, Medicare, Federal Institutions (Active Military, Veterans Administration, Community Health Centers, Native American Health Services, Corrections, Ambulatory Health Services at Federal Institutions, and Congress itself), State and Community Institutions (Corrections, Mental Disability Commitment), Colleges and Universities (Student/Employee Health), Philanthropy and third-party Liability. );
- a PRIMARY PHYSICIAN EDUCATION PLAN to promote the availability of physicians, advance practice registered nurses, and physician assistants for the enhanced Primary Healthcare of every resident person; AND
- a HEALTH SECURITY CERTIFICATION PLAN for qualification by an enhanced Primary Healthcare Clinic, community by community, as the basis for it to receive augmented financial support.
The PRIMARY HEALTHCARE BENEFITS PLAN (PHBP) would standardize the basic definitions and structure of the healthcare benefits eligible for reimbursement by any third-party or another source of financial support for the Basic Healthcare Needs of each resident person. The PHBP may require up to 4 years to be fully defined as it incorporates the recognition of special regional, State, and local 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 PLAN and 2) a reporting system to monitor the augmented reimbursement for the health care offered by a Primary Healthcare clinic that is HEALTH SECURITY certified, i.e., “enhanced.”
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, under-graduate 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 regional medical school involvement with each District Coalition and their nine or more Community HEALTH Forums.
The HEALTH SECURITY CERTIFICATION PLAN ( HSCP ) would be the responsibility of each District Coalition. To implement this certification, each District Coalition would be guided by the priorities established by their respective Regional Council as a result of authority assigned to it by the Board of Trustees. As a ‘rule of thumb,’ each District Coalition would eventually be responsible for the certification of approximately 1000 Primary Healthcare clinics, as a group capable of offering enhanced Primary Healthcare to approximately 4 million resident persons. Reporting to each District Coalition, nine or more Community HEALTH Forums would monitor the equitable availability of Primary Healthcare for their approximately 400,000 resident persons.
Any Primary Healthcare clinic achieving HEALTH SECURITY certification would be eligible for augmented reimbursement. The extra financial reimbursement would be necessary to support the level of Primary Healthcare necessary to achieve and sustain the requirements of HEALTH SECURITY certification. One standard for this certification would require the participation of its Primary Physicians (and their associated APRN and/or PA) in the nationally defined continuing education process sponsored by NATIONAL HEALTH. Eventually, HEALTH SECURITY certification would assure that each certified Primary Healthcare clinic offers health care along with a level of medical TRIAGE that enhances the clinic’s capability to offer equitably available, ecologically accessible, justly efficient, and reliably effective for each resident person.
Promoted by the new strategy, adequately financed and certified Primary Healthcare would represent the foundation for a high-quality healthcare industry. 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 primarily by the equitable availability of enhanced Primary Healthcare offered within each community to its resident persons, as promoted by NATIONAL HEALTH. To facilitate a continually reforming healthcare industry, the Board of Trustees would establish a Policy for the Regional Councils that would define their responsibility for monitoring the progress of the Strategic Projects Plan
PRIMARY HEALTHCARE
CARING RELATIONSHIP may be defined as
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a social interaction involving two persons
that begins with beneficent respect for each other’s autonomy,
thrives by each person’s steady renewal of their adaptive skills, and
flourishes from a timely intent to communicate ‘in harmony’
with warmth, non-critical acceptance, honesty, and empathy.
For the Initiative, 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 an enhanced level of 24/7 medical TRIAGE. The GLOSSARY for HEALTHCARE Sub-Page offers a succinct 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 may eventually require 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 for integrating both availability and accessibility then becomes transferable more easily maintained during maternal healthcare. More importantly, the reduction of maternal mortality will also require a nation-wide improvement of social cohesion. Additionally, enhanced social cohesion will be required to achieve a national improvement for child maltreatment, childhood obesity, adolescent suicide/homicide, substance abuse/mortality, homelessness, mass shootings, mid-life depression/disability, and senile dementia.
In addition to 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, chronic pain, or homelessness, another physician specialist might be 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 for medical TRIAGE when a new HEALTH Condition has occurred. A Primary Physician’s Health Care Team would likely include either a Physician Assistant or Nurse Practitioner.
To offer justly efficient and reliably effective health care for a resident person’s Basic Healthcare Needs and to simultaneously coordinate this health care with any Complex Healthcare Needs, each person and their Primary Physician will need a well-established caring relationship. The communication attributes of warmth, non-critical acceptance, honesty, and empathy apply as initially studied by Carl Rogers, Ph.D. (Rogers 1963) These attributes become most important for assuring that a person’s life-goals are respected during any severe Unstable HEALTH crisis.
To support a caring relationship for each resident person’s healthcare, the leadership of our nation’s entire healthcare industry will collectively need to embrace a unified set of PRINCIPLES as a basis for their leadership decisions. When the pervasive influence of Altruism, Cooperation, Reciprocity, Trust, and Excellence occurs at each level and scale of the healthcare industry, the resultant synergy would assure that the new strategy is increasingly honored each time a resident person encounters a new HEALTH Condition and contacts the medical TRIAGE service offered by their Primary Physician.
As noted above, the professional skills underlying our nation’s Primary Healthcare will require continuous adaptation and improvement. In 2015, a total of 11 medical schools did not directly offer a residency program for Family Medicine. Eight of these schools existed in the Northeast sector of our nation, representing 100 million citizens.
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.
A nationally supported and sanctioned new strategy for the advancement of Primary Healthcare will indirectly promote improvement at all levels of the healthcare industry. In effect, the new strategy offers a clearly definable process of institutional renewal for our nation’s entire healthcare industry. 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 nation-wide improvement of social cohesion as driven by the persistently reciprocal contributions of social capital by neighboring communities to each other’s Survival Commons.
Currently, total health spending for our nation’s healthcare is incompatible with the level of economic stability necessary to preserve our nation’s autonomy within the worldwide community, especially the market-place arena for its Resources. This is true for each resident person, especially if we are to continue our nation’s commitment to supporting the Survival Commons of each community. The Knowledge applicable for the reform of our nation’s healthcare industry already exists. Given the worsening uncertainty of our times, 2021 is the year to begin the application of this Knowledge.
REGULATORY CONTROL
Whether or not the Initiative 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 Initiative Page and its Sub-Pages describe an institution that would promote healthcare reform primarily based on a connection to community needs as supported by the District Coalitions. A Community HEALTH Forum would be formed by local initiative including any requirements for its administrative support, each for approximately 400,000 resident persons. NATIONAL HEALTH would define a process for the properly constituted formation of these volunteer efforts and authorize support in the form of technical assistance and a national connection with the other 728 or more Community HEALTH Forums.
The initial and continuing recognition of each Community HEALTH Forum would occur based on a policy established by the Board of Trustees for the respective Regional Councils and their District Coalitions. These Operational Statements would require an annual assessment of Unstable HEALTH, community by community. This assessment would lead to a written Community HEALTH Plan for improving the Stable HEALTH of their community’s resident persons, neighborhood by neighborhood.
These Community HEALTH Plans would annually report the local status of Primary Healthcare and its equitable availability. Each annually updated edition of a Community HEALTH Plan would also describe the community originated collective action projects in place for resolving the deficits associated with the availability of Primary Healthcare as well as for the other community attributes adversely influencing the occurrence of Stable HEALTH within its neighborhoods, e.g., 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 its unpredictable disasters.
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. This Initiative, as well as any other comprehensive proposal for healthcare reform, requires an understanding of the legal, medical, social, economic, and innovation traditions as a basis for 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.
NATIONAL HEALTH represents a means to redirect the root causes underlying the current paradigm paralysis of our nation’s healthcare industry. The research of Professor Elinor Ostrom supports the structure of this plan: 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 equitably available as well as ecologically accessible, justly efficient, and reliably effective Primary Healthcare for every resident person, community by community? The new regulatory controls, that the Initiative would establish, will require the direct involvement of the affected healthcare institutions in their own self-regulation. The over-riding purpose for the new regulatory controls is our nation’s need for a systematic renewal of enhanced Primary Healthcare, community by community and neighborhood by neighborhood.
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 or effective for a rapidly worsening, new HEALTH Condition. This is an especially dangerous situation for a resident person with fundamentally Unstable HEALTH as in diabetes, emphysema, or cancer. For infants, the disabled, the homeless, and women during a pregnancy, the risk of Unstable HEALTH complications 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 and, eventually, ecologically accessible by each person. In addition, every community’s resident persons are unlikely to achieve the most optimal resiliency for their HEALTH unless their Family resides in a community characterizable as a Blue Zone (Buettner 2012).
The most important attribute of enhanced Primary Healthcare is its responsiveness to unexpected changes in the HEALTH of each person who 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 inadequacy represented by too many resident persons without enhanced Primary Healthcare represents the fundamental barrier requiring resolution to achieve healthcare that is the most efficient and effective for our nation’s resident persons as compared to all 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. By 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. I propose a GOAL for NATIONAL HEALTH that would represent a reduction in the annual health spending for our nation’s healthcare industry, within our national economy, by a relative total of 37%.
Beginning in 2020, this change would eventually represent a decrease from 18.0% to 13.0% of the gross domestic product in 2031. During these 10 years, the change would represent a decrease of 0.5% annually by our health spending as a portion of our nation’s economy, our Gross Domestic Product, viz 18.0% minus 5.0% equals 13.0%. Depending on our nation’s economic growth in the future, the change for a given year may not require an actual decrease in total health spending for that year, viz. see last quarter of 2019 (Altarum 2020). Most importantly, a reduction in our nation’s health spending for healthcare would represent a major improvement in our ability to preserve each community’s Survival Commons and to sustain our nation’s autonomy within the worldwide community, especially the market-place 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 by 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 will acknowledge the difficulties associated with remodeling the current paradigm paralysis 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 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 wide-spread 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 will enable the affairs of NATIONAL HEALTH.
the FIRST GOAL
The Congressional Charter will 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 world-wide economy, I propose 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% 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 three national projects. Averaged over ten years, attaining this GOAL would represent an annual return on investment (ROI) of 200:1 !
the SECOND GOAL
Beginning in 2009 as compared to 1969, a stomach ulcer, heart attack, or measles (25) would have been a very rare occurrence for anyone within a resident person’s Family and their Extended Family. These and many other improvements have occurred in the last fifty years for the benefit of each resident person’s HEALTH. Based on these and similar improvements, we believe that our nation’s HEALTH and its healthcare industry has the potential to become clearly the best in the world. But, as compared to 1969, there are certain life-threatening health conditions that still affect too many Families and their Extended Families.
This Initiative 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 (12), the maternal mortality ratio in 2015 for our nation’s women ranked 4 2 n d w o r s t 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 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.
As sponsored by enhanced Primary Healthcare for every resident person, a renewed tradition of equitably available and ecologically accessible health care for Primary Healthcare should be the most important step for stabilizing the HEALTH of any woman who is or may become pregnant. The states of Alaska and Massachusetts should receive a national Prize. From 1986 through 2014, they maintained a maternal mortality ratio within the best cluster of states for all three separately sequential, state by state, and prolonged-interval data-sets. The most recent national data-set was reported in September of 2016 for 2005-14.
With focused Congressional action, NATIONAL HEALTH could soon augment the current efforts for improving maternal health. 2021 is the year to begin improving the health care for any resident person with Complex Healthcare Needs, especially for women during a pregnancy. As a measure of our nation’s healthcare that has become increasingly unavailable and inaccessible, I propose a second GOAL for the Congressional mandate of NATIONAL HEALTH. Along with the first GOAL, a 70% reduction in our nation’s maternal mortality ratio would represent the second GOAL. By 2031, our nation’s mothers deserve no less. Within 6 months after its authorization, NATIONAL HEALTH could be a reality for improving the 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 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 and, especially, within every community.
Integrating the depth and breadth of the three 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 Initiative.
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 healthcare industry needs is NATIONAL HEALTH, a new nationally sanctioned institution to sponsor the reform it desperately needs, community by community. This new strategy 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 each resident person, community by community, 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 Initiative for the reform of our nation’s healthcare industry. Truly, a historic commitment will be necessary to improve our nation’s healthcare for our citizens encumbered with adversity and especially for each 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 wide-spread use. Its context for NATIONAL HEALTH deserves 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, anthropological, and human suffering phenomena. Given the full definition of HEALTH as associated with NATIONAL HEALTH, it is possible to anticipate how complicated the reduced resiliency underlying a person’s Unstable HEALTH, it’s Diseases, can become.
AVAILABLE & ACCESSIBLE
These two QUALITY attributes of healthcare occur frequently within discussions of 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 and applies to 330 million resident persons. This commitment reflects a priority that success will ultimately be associated with the social capital occurring among the relationships and responsibilities required for its implementation. With approximately 720 Members (Trustees and Committee members) and Associates (employees) along with 7200 Advocates (800 Community HEALTH Forums), every possible means to avoid cognitive dissonance will be required. The Global Tasks set the outline for producing the Policy and Procedure OPERATIONAL STATEMENTS for NATIONAL HEALTH. They are: ORGANIZE SYSTEMS, PURSUE ‘VIVION’, BUILD COMMUNITY, MANAGE RESOURCES, and DEVELOP SKILLS. It is likely that Stephen B. Covey would be engaged to assist this endeavor, given his career-long study of this phenomenon. (Covey 2002)
“PARKINSON’S LAW”
This is the title for a small book written by C. Northcote Parkinson and first published in 1957. The book is best characterized 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.