enlightened competition
G O A L S
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INTRODUCTION
SUCCESS
“We are here on earth
to live, grow up, and do what we can do
to make this world a better place
for all people to enjoy freedom.”
Rosa Parks (1913 – 2005)
“I have learned that people will forget what you said,
people will forget what you did,
but people will never forget how you made them feel.”
Maya Angelou (1928-2014)
Most likely, Ralph Waldo Emerson was the author of this poem. Several other authors published similar versions during the 19th century. The Emerson version still resonates best with its special presence for defining the successful pursuit of each person’s life. This presence would be a worthy attribute for the involvement of anyone, such as a Community Advocate, who is willing to support the fundamental reform of our nation’s healthcare during their lifetime. With the special involvement of these persons as Advocates for a Community HEALTH Forum, the mindfulness of “Success” could also be an effective counterbalance to the pervasive “mindless menace of violence” passionately described by Seator Robert Kennedy during his Presidential campaign in 1968.
I suspect that one underlying attribute, among many, of each person’s healthcare is competition. Specifically, this competition can occur daily among the economic, professional, or personal priorities of each healthcare provider, unexpectedly and unintentionally, in subtle ways. To achieve the attributes of individual success as described by Emerson, any person – profesional provider or not – who is dedicated to improving the Unstable HEALTH of another person will need to steadily revise the special priorities of their obligations. These continually reassessed priorities would then promote a commitment *) to eliminate any awareness or motive of unbalanced competition during the decision process that occurs for each health care encounter and *) to openly acknowledge any relevant, apparent or real, conflicts of interest: personal, professional, or economic. To disengage these conflicts-of-interest, the descriptive term that would be most applicable is ‘enlightened competition.’ Enlightened competition would apply to the multitude of interacting dimensions that underlie the character of any encounter for healthcare, not just the economic factors. For any professional caregiver, what should healthcare reform do to improve the institutional support for their professional career, especially for a Primary Physician? This institutional priority should focus on supporting each caregiver’s commitment to establish an enduring caring relationship during each person’s health care encounter that will sustain this person’s autonomy.
The simultaneously diverse dimensions connected with an episode of health care can rise to an overwhelming level of complexity. These dimensions may involve a consideration of timeliness, information precision, diagnostic assessment diversity, therapeutic options, patient acceptance, social interaction spontaneity, relevant documentation, resource allocation, as well as its ethical issues, especially beneficence and futility. Currently, the traditions of our nation’s healthcare do not adequately support a commitment to consider these healthcare dimensions carefully during each health care encounter. Redirecting our nation’s healthcare traditions to improve the alignment of these dimensions is an underlying goal for the NATIONAL HEALTH Proposal as focused by its associated set of PRINCIPLES. Striving to achieve Emerson’s state of “Success” could be a multi-dimensional yardstick for anyone contributing to our nation’s healthcare, especially when this health care is offered with a daily awareness of ‘enlightened competition.’
enhanced PRIMARY HEALTHCARE
The NATIONAL HEALTH Proposal would compile a set of Operational Statements to support a renewal of Primary Healthcare for the Basic Healthcare Needs of each community’s resident persons. These Operational Statements would rely on the PRINCIPLES of Altruism, Trust, Cooperation, Reciprocity, and Excellence to promote the Global Institutional Tasks applicable for assuring the equitable availability and ethnographical accessibility of enhanced Primary Healthcare, community by community. To benefit from these Operational Statements, the NATIONAL HEALTH Proposal would specifically prompt the formation of local efforts to assure that enhanced Primary Healthcare steadily becomes equitably available for each resident person within their own community. This new strategy would engage the locally prominent stakeholders to join a collaborative process for resolving the neighborhood inequities underlying the availability and accessibility of their own community’s Primary Healthcare.
With the assistance of three national projects, this new strategy would support the evolution of enhanced Primary Healthcare with an awareness of ‘enlightened competition’ for reconciling the dimensions affecting the outcome from any encounter for the health care of Basic Healthcare Needs. Slowly but surely, enhanced Primary Health Care would be refocused by its connection with the NATIONAL HEALTH PRINCIPLES. Beginning with Primary Healthcare, promoting ‘enlightened competition’ would secondarily refocus the character of this health care to continuously curate a conprehensive Care-Plan that includes any Complex Healthcare concurrently being offered to each resident person.
With Primary Healthcare at the leading edge of change, ‘enlightened competition’ would become an essential attribute for our nation’s entire healthcare industry. The increased attention to a careful reconciliation of the competing attributes applicable to each episode of health care would support the reforms necessary to release the paradigm paralysis afflicting our nation’s entire healthcare industry. Between 1969 and 2009, the paradigm shift that occurred was the result of a rapidly evolving improvement in the level of specialized health care that was available for Complex Healthcare Needs. The health care for Complex Healthcare Needs has economically evolved in the absence of a corresponding improvement in our nation’s health care for Basic Healthcare Needs, especially its equitable availability and ethnographical accessibility within every community.
To resolve the paradigm paralysis afflicting our nation’s healthcare, a high level of ‘enlightened competition’ as an attribute of enhanced Primary Healthcare could produce the day-to-day synergy necessary for steady change. Within fifteen years, unlocking the paradigm paralysis affecting our nation’s healthcare will be especially necessary given 1) our changing world-wide community, 2) the “mindless menace of violence” affecting each community, and 3) the deficient financial resources currently available to achieve the equitable availability of enhanced Primary Healthcare for each resident person, community by community. For each Healthcare Team Member who supports the new strategy of the NATIONAL HEALTH Proposal, a commitment to ‘enlightened competition’ will be their pathway to an inner presence of “Success” as described by Ralph Waldo Emerson.
initial GOALS
A Congressional Charter would define the initial GOALS for NATIONAL HEALTH and its underlying governance. A preliminary proposal for the initial GOALs should represent the following:
I. Establish THREE NATIONAL PROJECTS within 2-years for improving the healthcare offered
to each community’s resident persons by:
* Maintaining a PRIMARY HEALTHCARE BENEFITS PLAN as a set
of minimum standards to define the healthcare benefits eligible for the financial support
of each resident person’s Basic Healthcare Needs by any form of economic resources,
* Coordinating an evolving statement for a PRIMARY PHYSICIAN EDUCATION PLAN
with our nation’s medical schools as a general format for the under-graduate and
post-graduate education of physicians as the basis for assuring the uniform availability
of Primary Physicians who individually accepts a personal responsibility to pursue
their career’s profesional renewal by continuously acquiring the adaptive skills
as prompted by the PRIMARY HEALTHCARE BENEFITS PLAN, and
* Establishing HEALTH SECURITY certification for the clinics offering
enhanced Primary Healthcare as the basis
^ to improve each person’s health care for their Basic Healthcare Needs including
its coordination with any Complex Healthcare Needs and
^ to apply their clinic’s augmented financial support to offer broadly
enhanced Primary Healthcare;
II. Sponsor a NEW STRATEGY to uniformly improve our nation’s Population HEALTH by
* Promoting at least 729 Community HEALTH Forums throughout our nation
that are individually comprised of multiple counties or parts of a county
to encompass, on average, 400,000 resident persons as the basis
to form a collective action strategy for defining an annually revised
Community HEALTH Plan that will assure that equitably available and
ethnographically accessible enhanced Primary Healthcare is offered
to each of their resident persons as the basis to begin reducing
the annual health spending for our nation’s healthcare as a portion
of our nation’s economy (GDP) by 5% within 5 years and
27% within 15 years,
* Resolving the generational, locally driven ecologic and cultural traditions that
adversely impact too many resident persons of every community by including
within each Community HEALTH Forum’s, Community HEALTH Plan
^ a Master Disaster Preparedness Plan that assures a connection with adjacent
communities along with their State and Federal preparedness plans and
^ an assement of the community’s Survial Commons (aka safety net) –
especially its deficits applicable to neighborhood violence,
family nutrition, housing code-enforcement, early childhood education,
ending homelessness, as well as initial employment entry, and
* Supporting the HEALTH SECURITY certification of Primary Healthcare clinics,
community by community, that will achieve justly efficient and
predictably effective healthcare for each of a Forum’s resident persons
as measured by a 70% reduction of our nation’s annual maternal mortality ratio
within 15 years; AND
III. Achieve wide-spread, broadly based national support for the affairs of NATIONAL HEALTH
and its PRINCIPLES of Altruism, Trust, Cooperation, Reciprocity, and Excellence by:
* Achieving supportive ratification of its Congressional Charter by 30 states within 5 years,
* Recognizing the officially operating existence of 500 Community HEALTH Forums
within 5 years, and
* Recognizing 30,000 HEALTH SECURITY certified Primary Healthcare clinics
within 5 years.
The initial GOALS will reduce the annual health spending for our nation’s healthcare as a portion of our national economy within 5 years by 5% (from 18.0% in 2019 to 17.1% in 2024) and within 15 years by by 27% (from 18.0% in 2019 to 13.0% in 2034) as measured by health-spending’s portion of the annual gross domestic product. For example, the differece of our nation’s healthspending between 18.0% and 13.0% of our nation’s gross domestic product (GDP) for 2019 alone would have represented $1 Trillion. Remember, the faster our economic growth occurs between 2019 and 2034, the actual reduction in absolute health spending as a portion of our nation’s GDP would be less than the estimate given for 2019 within the 2034 GDP.
In fact, it is likely that a slowing of the annual increase in health spending to a level that it is less than economic growth will in and of itself support improved economic growth. From an accounting principle, the underlying objective is to lower health spending increases to a level that is 0.5% less than economic growth. For instance, if economic growth was 3.0% for 2019, any increase in annual health spending should be 2.5% or less. By assuming that health spending growth was 1/2 of 1% less than economic growth, it would only take 10 consecutive years to achieve health spending that represented 13.0% of our national economy. For perspective, the total cost of the Iraqi-Afghanistan War in 2005 was $100 Billion. Reducing our nation’s health spending in 2019 by $1 Trillion would have represented the equivalent of fighting 10 Iraqi-Afghaniston Wars sinultaneously during 2005 !
In addition, the initial GOALS will reduce the number of women who die as a result of a pregnancy. As monitored by standards of the European based ‘Organization for Economic Cooperation and Development’ (OECD), the maternal mortality ratio for our nation worsened from 15.1 in 2005 to 17.4 in 2018. Meanwhile, the 14 European nations with the best maternal mortality levels averged 5.0 in 2005 and 3.9 in 2018. Using the statistics for 2018, the NATION HEALTH Proposal’s GOAL of decreased maternal mortality by 70% would mean that at least 400 of the 600 of the women who died with a pregnancy in 2018 would have still been living in 2021.The number tends to be ignored, for complex reasons, since there were nearly 4 million births in 2018. When women die in association with a pregnancy, the human capital lost by their Family is profound, especially for each of these Families who already have children.
To rank among the 14 nations with the best maternal mortality ratio in 2018 (Australia, Finland, Ireland, Italy, Sweden, Netherlands, Spain, Germany, Switzerland, Denmark, Norway, Canada, United Kingdom, and New Zealand), the number of maternal deaths in 2018 for our nation’s women would have been less than 300. To understand the implications on the over-all HEALTH within a Family by a maternal death, see the RATIONALE Sub-Page for a contemporary (viz. Anthropocene) Definition of HEALTH. The level of denial within the current PARADIGM of our nation’s healthcare regarding its high level of maternal mortality is the most important attribute of its underlying paralysis. It represents our nation’s most fundamental HEALTH problem that defines the emergent immediacy for implementing the NATIONAL HEALTH Proposal.
GETTING STARTED
When the initial Meeting of the Board of Trustees occurs, the time clock for NATIONAL HEALTH will start. During the 2022-23 session of Congress, submitting the authorizing legislation for NATIONAL HEALTH to the President should be the number one task for the leadership of Congress. The Board of Trustees could initiate its affairs within 6 months after the President’s signature. Reforming our nation’s healthcare industry with a V I S I O N to achieve Stable HEALTH For Each Resident Person, community by community, could also be a factor for reducing the “mindless menace of violence” described by Senator Robert Kennedy during his Presidential campaign in 1968.
Improving the equitable availability, ethnographic accessibility, just efficiency, and predictable effectiveness of our nation’s healthcare industry is desperately needed. Since 1969, there has been an increasing tendency to define healthcare based on one or more specialist’s expertise for each narrowly defined health condition. This scenario has progressively reduced the precision applied to each reident person’s Population HEALTH as well as its Healthcare. In the absence of enhanced Primary Healthcare, the reduced precision has especially affected our resident persons who have multiple Complex Healthcare Needs as well as social adversities. For a Federal fixed-cost of $1.50 per resident person annually, NATIONAL HEALTH would establish a precisely coordinated reform of our nation’s healthcare traditions. The new strategy represents an effort to mobilize local and regional resources to assure that the health care for Basic Healthcare Needs is uniformly improved, community by community.
Each newborn infant, every disabled or homeless resident person, and all women during and after a pregnancy are waiting. For at least one of every twenty of our nation’s resident persons, tomorrow may not be soon enough!
future GOALS
The Congressional Charter should not define any GOALS for the future affairs of NATIONAL HEALTH. The Congressional Charter would only PROHIBIT any long-term involvement with the direct distribution of economic support for any resident person’s health care. The importance of NATIONAL HEALTH for our nation’s healthcare lies in its precisely defined reduction of the conflicts-of-interest that promotes a deficient commitment to the humanitarian mandate as compared to the scientific mandate for our nation’s health care. Currently, the institutions that pay for our nation’s healthcare also largely determine the benefits eligible for this reimbursement. This conflict-of-interest, among others, would be reduced since the Congressional Charter would assign to NATIONAL HEALTH the responsibility of determining the minimum standards applicable to any definition of the healthcare eligible for the economic support of each resident person’s Primary Healthcare.
Eventually, the affairs of NATIONAL HEALTH would encounter ‘other needs’ for the HEALTH of each resident person. Any future GOALS may not begin to be definable until 6-7 years after the initial Meeting of its Board of Trustees. Given our nation’s heritage, it is possible that three attributes of our nation’s HEALTH would benefit from the future collaborative character of NATIONAL HEALTH. The future GOALS in ten years will probably evolve from resolving the deficiencies of social cohesion that already exist within each community. As of now, these deficiencies could prompt NATIONAL HEALTH to eventually:
* Foster a national dialogue about a continuously revised Comprehensive National Risk Management Plan, locally adapted community by community, for any national disaster requiring a locally coordinated response by our nation’s healthcare industry, such as an unforeseen pandemic or a catastrophic earthquake along the oceanic coast of Washington, Oregon, and California;
* Focus the affairs of NATIONAL HEALTH to emphasize equitably available and ethnographically accessible health care for each resident person’s Basic Healthcare Needs as the basis for any future economic need to ration the healthcare for Complex Health Needs. This economic need should be governed by an ethical standard that is informed by the justly efficient use of Resources; AND
* Sponsor a continuously renewed assessment of the future requirements for the evolving reform of our nation’s healthcare industry that reflects an ANTHROPOCENE perspective regarding the Knowledge, Resources, and Human Dignity applicable to each resident person’s HEALTH.
DISCUSSION
RISK MANAGEMENT
If another serious world-wide pandemic were to occur, who would establish the locally applicable ‘medical TRIAGE’ processes necessary for the appropriate use of limited national healthcare resources? During an unusually severe influenza outbreak, who would be authorized to identify the person with a severe illness who would have access to the last ventilator in a hospital’s intensive care unit? The decision process would be especially difficult since many resident persons with breathing distress from an influenza pandemic would be young children, and many adult hospitals may not be prepared for the number of victims who would be children. Currently, a nationally defined ‘medical TRIAGE’ process could be established by the combined efforts of Congress, the Public Health Service, the Surgeon General, our medical schools, and each state’s Health Department. However, there currently is no nationally sanctioned institution with community connections and trustworthy traditions that could responsively reconcile the proposals formulated by this combination of public and private institutions.
The NATIONAL HEALTH Proposal creates an opportunity to foster a national dialogue as a basis for planning any over-all decision structure applicable to another serious pandemic or another disaster overwhelming our nation’s healthcare resources, be it regional or national. With Congressional authorization of NATIONAL HEALTH and its role in promoting beneficial healthcare reform, it could eventually accumulate the nationally recognized and widely supported authority to sponsor a national Risk Management Plan for our nation’s HEALTH. Specifically, this sponsorship would foster an evolving, justly efficient model for managing regional or national Healthcare Disaster prevention, mitigation, and amelioration at the community level. In effect, the ultimate benefit from NATIONAL HEALTH for our nation’s healthcare would be its existance as an institution with a widely accepted, trustworthy reputation. Importantly, this trustworthy capability would be most important for reconciliing *) the vested interests of the scientific mandate to pay for our nation’s healthcare with *) the vested interests of a humanitarian mandate to arrange the greatest good for the greatest number of resident persons, community by community.
JUSTLY EFFICIENT
Given the economic traditions of our nation’s healthcare, it may ultimately be too difficult – or even unnecessary – to eventually implement a uniform basis for the reimbursement of any person’s Complex Healthcare Needs, if any. The initial degree of wide-spread acceptance and support for the description of minimum Healthcare Benefits just for Basic Healthcare Needs may be the best predictor of any future effort that could be applied to Complex Healthcare Needs. The NATIONAL HEALTH sponsored dialogue for establishing the minimum definitions for a national Certificate of Benefits applicable to Primary Healthcare will involve various compromises among the legitimate vested interests including a provision to allow State by State definitions for certain specific Benefits, such as fertility and the special newborn detection of congenital metabolic disorders. Hopefully, a national Certificate of Benefits would also achieve a level of resident person trust that any, apparent or real, future level of rationing would be applicable to every resident person, especially in the event of a national or regional disaster. To achieve this level of support, a high level of Trust, Cooperation, and Reciprocity that is intentially sustained would establish the wide-spread acceptance of NATIONAL HEALTH and its Board of Trustees, nine Regional Councils, eighty-one District Coalitions, and ‘729 plus’ Community HEALTH Forums.
The formal governance for NATIONAL HEALTH would promote a Community HEALTH Forum for each of at least 729 communities, each focused on the HEALTH of their own resident persons. Established through local initiative, each Community HEALTH Forum would sponsor the collective action strategies, community by community, applicable to assure that enhanced Primary Healthcare is at least equitably available to and ethnographically accessible by each resident person within their own community. I propose that a widespread interaction by each Forum with the Forums of their adjacent communities could also be the best means to assure that any national disaster plan involving our nation’s HEALTH reconciles the national and regional needs with its locally applicable implementation. This level of collaboration may be an important outcome to improve our nation’s declining social cohesion.
The academic studies that formed the basis for “Governing the Commons” by Professor Elinor Ostrom (2005) are especially applicable to the shared use problems related to our nation’s healthcare. It is highly unlikely that the Accountable Care Act of 2010 will achieve a sufficiently efficient healthcare industry for resolving its evolving “Tragedy of the Commons.” NOW is the time to apply the collective action solutions defined by Professor Ostrom. A Nobel Prize winner in 2009, she died in May of 2012. Her award represented the first woman selected as a Nobel awardee in Economics (the second occurred 10 years later in 2019). In her honor, I propose a personal intent for this NATIONAL HEALTH Proposal. The initial Meeting of the Board of Trustees should occur in May of the year.
CONTINUOUS REFORM
With a Congressionally fixed, population-based and COL adjusted budget, the possibility of a progressively intrusive involvement in the day-to-day affairs of each resident person’s health care by NATIONAL HEALTH could be prevented. Given a progressive improvement in the health spending ‘for’ and the quality ‘of’ our nation’s healthcare, what then would be the continuing role of NATIONAL HEALTH for our nation’s HEALTH and its HEALTHCARE? The level of uncertainty given the future turmoil throughout our world is profound. The worldwide community and the marketplace arenas for its Resources, Knowledge, and Human Dignity are at stake. We must never again allow the healthcare industry to jeopardize our nation’s autonomy within the world’s marketplace arenas, especially for its Resources. Very likely, a constant and continuously adjusted long-term plan for healthcare reform will always be necessary for our nation. This view of permanent adaptation may be most clearly recognized by the words of President Thomas Jefferson, most widely accessible by their reproduction within his memorial at the Tidal Basin in Washington, D.C. [ see the EPILOGUE Sub-Page ].
Continuously sponsored, healthcare reform will be necessary to achieve Stable HEALTH for each Resident Person, especially as it contributes to improving our nation’s pervasive loss of social cohesion and its associated decrease in social mobility. This improvement would be most-precisely measured by a reduction of our nation’s death rate from homicide and suicide for citizens aged 1 year thru 24 years. In 2010, it was 25%. With improvement of the social capital asset of each community by their Community HEALTH Forum, I propose a goal of reducing this mortality rate to 20% of all deaths within this age group. The presence of nearly 800 Community HEALTH Forums could have a sentinel benefit for a further reduction to 17%. A reduction in the level of violence as an attribute of our nation’s POPULATION HEALTH would represent a broad measure of nationally improved, social cohesion from the affairs of NATIONAL HEALTH. This community-based focus for healthcare reform may be our most valuable national asset as we re-focus our nation’s autonomy within the world’s marketplace arenas for its Resources, Knowledge, and Human Dignity. In effect, the future heritage of our nation’s autonomy within the world-wide community is at stake.
ROSA PARKS and MAYA ANGELOU
Are we not lost in our nation’s cultural and ecologic adaptation to the rapidly evilving world order of the ANTHROPOCENE since WWII? The authenticity of these two authors should indelably remind us about our fundamental duty to care for and about each other. Return to the 2nd page and read again their admonitions cited above.
S U B P A G E S
supportive GOALS The initial function of NATIONAL HEALTH focuses on the two-fold importance of 1) enhanced Primary Healthcare for the promotion of a precisely focused healthcare industry characterized by a high level of efficiency, accessibility, efficiency and effectiveness and 2) a national, community by community, strategy to improve its social cohesion deficits. When the initial benefits of this combined strategy begins to demonstrate success, there are several other attributes of our nation’s HEALTH and its HEALTHCARE that may demonstrate a need for newly prioriitized, community-driven attention. This Sub-Page offers a discussion of the long-term needs underlying our nation’s POPLULATION HEALTH that may potentially benefit from the focused, analytic experience of a semi-autonomous NATIONAL HEALTH institution.
GENERAL OPERATING PRINCIPLES Promoting a responsive and inclusive focus for the affairs of NATIONAL HEALTH will be difficult. Meaningful healthcare reform will need a national level of goodwill and commitment probably not witnessed since WWII. To sustain this level of goodwill and commitment, I propose that a carefully crafted system of OPERATIONAL STATEMENTS could more precisely define the boundaries for promoting reform every day as the Congressional Charter becomes a widely supported reality. The structual format of this OPERATIONAL STATEMENT establishes a clearly defined, derivative structure as the basis to establish the governance dimensions required for NATIONAL HEALTH to improve our nation’s POPULATION HEALTH as well as its HEALTHCARE.
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initial GOVERNANCE Of essential importance for the initial Meeting of the Board of Trustees, the governance of NATIONAL HEALTH should represent a carefully structured basis for defining its derivative levels of responsibility and accountability. The Members attending the initial MEETING should represent the result of a unique and expedient selection process. Three years after the initial MEETING, a permanent selection process would become active. The selection processes at the beginning would eventually merge into the permanent process as defined by the Congressional Charter. This Sub-Page describes a proposal for an expedient selection of Members for the initial Meeting of the Board of Trustees.
STRATEGIC PROJECTS PLAN The GENERAL OPERATING PRINCIPLES Policy would require several Procedures to implement its intent. The most important of these is this Procedure with its broad plan for achieving the GOALS of NATIONAL HEALTH. This Sub-Page represents an OPERATIONAL STATEMENT for implementing an optimal starting point for the affairs of NATIONAL HEALTH.
HEALTH SECURITY certification It is likely that the criteria and process of certification for enhanced Primary Healthcare will require a special effort to promote change through a carefully defined process. Given access to enhanced reimbursement for a certified Primary Healthcare facility, this evaluation process will require a nationally conceived consensus. The institutional format for this process will probably evolve in conjunction with the evolving affairs of NATIONAL HEALTH. The process is defined initially to require a set of minimum requirements and a clinic’s steady imrovenent toward achieving the ultimate level of compliance within three years. The analysis of this clinic-by-clinic progress will be publicly reported for any ‘resident person’s comment” by each District Coalition.
COMMENT The HEALTH SECURITY certification will require each clinic to offer licensed RN personnel as the clinic’s telephone ‘initial responder’ for medical TRIAGE assitance. Promoting this level of trustworthy responsiveness by each Primary Healthcare clinic will, within 18-24 months, reduce this clinic’s hospital utilization rates by 10-15%. This reduction of hospital utilization could achieve a 25-30% decrease by a “capitated, risk-sharing, and referral-preauthorization” controled, insurance model. Remember, Trust and Self-Reported Well-Being have been verified by population studies to exhibit reverse causality.
This page has the following sub pages.