h u m a n i t a r i a n m a n d a t e
s u p p o r t i v e G O A L S
INTRODUCTION
V O L U N T A R I S M
“VOLUNTARISM is a theory of action according to which the will takes precedence over the intellect. The will is traditionally understood as the faculty that forms intentions, and makes decisions and choices. The intellect is understood as a cognitive power, with both theoretical and practical components. The theoretical intellect is responsible for thinking and forming beliefs, whereas the practical will is responsible for forming judgments regarding what is best to do.” (44)
The analysis of history could easily identify instances of social or political change based on the will as well as instances of change fostered by the intellect. Queen Elizabeth I was the reigning monarch of England from 1558 thru 1603. To repair the financial status of her nation at the beginning of her reign, the intellect of Queen Elizabeth I decided to avoid her involvement in foreign wars or marriage to build her nation’s internal welfare. This commitment led to world-wide English prosperity for 300 years following her reign. The decision to use nuclear energy to end WWII may be another example of the will. Somewhere between will and intellect lies a dialectic underlying the evolution of social and economic change over time. This Blog reflects a bias that resolving the paradigm paralysis afflicting our nation’s healthcare industry should initially follow the intellect as represented by a strategy formulated from the confluence of uniquely connected ideas and concepts. Subsequently, the will of our nation’s humanity, community by community, will be necessary to sustain the initial release of the paradigm paralysis as the basis for a continuously self-reforming healthcare industry. Beginning the first day after its initial MEETING, NATIONAL HEALTH will depend on the will of individual citizens, community by community, who chose to mold their volunteerism through the intellect of collective action.
I. Initiate NATIONAL HEALTH with humility and honor by fostering –
* polycentric governance that promotes widely acknowledged, local community support;
* Career Achievement Plans by all Primary Physicians that will enhance the supply of Primary Physicians for the NATIONAL PRIMARY HEALTHCARE BENEFITS PLAN;
and
* renewed national traditions that demonstrate a higher level of social responsibility for
^ resolving the apparent, as well as real, conflicts of interest occurring among all of the institutions within the healthcare industry;
^ encouraging the participation of medical schools in the uniform promotion of HEALTH SECURITY certified Primary Healthcare clinics for each community’s citizens;
and
^ coordinating the financial support by Congress of each State’s primary responsibility to arrange universal health insurance for each of its citizens
AND
II. Promote a national commitment to –
DISCUSSION
NATIONAL HEALTH as proposed would be a monumental challenge for our nation. On its own, NATIONAL HEALTH would not succeed solely as a result of its new strategy or its meritorious ideals. At all levels of the healthcare industry, a voluntary acknowledgment of our nation’s heritage will be required, particularly as it applies to the current character of our nation’s healthcare. Rising up from the doldrums of our traditions will be required. We should not abandon them but redirect them for 1) the Basic as well as the Complex Healthcare Needs of each citizen and 2) the autonomy of our nation within the worldwide community of nations. As a democratic republic, we are a nation based on the most successful political and economic innovation among the world’s developed nations. Our nation now needs to focus on its humanitarian mandate for the Basic Healthcare Needs of each citizen. NATIONAL HEALTH could be the catalyst to help fulfill the heritage of our nation, especially its humanitarian mandate to enhance the Survival Commons within each citizen’s community.
GOVERNANCE
A special PERSPECTIVE written by John Iglehart appeared in the April 2, 2009 edition of the New England Journal of Medicine (15). The author presents the results of an analysis that compares the level of spending for our nation’s healthcare with the level of spending by 14 of the other, then, 42 developed nations of the world. It demonstrates a general correlation between the wealth of a nation and the nation’s annual spending for their citizen’s healthcare, except for the “United States.” Based on this analysis, our nation’s healthcare for each citizen may be spending 25-30% more of our national economy every year for healthcare than these other nations spend. This means that instead of spending 17-18% of our gross domestic product on national health care, it could be 12-13% with no change in its effectiveness. For our nation, this difference would have represented at least $1.05 trillion in 2018 alone. In 2015, an improved level of efficiency would have been more than enough to pay the healthcare expense for the 16 million citizens without health insurance and improve the financial condition of our nation’s Federal government. It is a very sobering analysis. The financial implication is simple. Inadequate efficiency is the principal problem of our nation’s healthcare industry.
Unseen and unrecognized, our nation’s level of healthcare inefficiency is the proverbial “elephant in the closet.” Also unseen and unrecognized, the “elephant” is profoundly affecting our nation’s economic participation in the world’s marketplace for its Resources. We are now a debtor nation rather than a creditor nation. This state of economic dependency diminishes our nation’s autonomy within the worldwide community and the world-wide marketplace arenas for its Knowledge and Human Dignity as well as for its Resources.
For improved efficiency, the Initiative Page and its Sub-Pages describe a bare-bones, precisely focused, new institution for sponsoring the reform of our nation’s healthcare. NATIONAL HEALTH would adapt the historic traditions of our nation’s healthcare as the basis for resolving the problems causing its inefficiency. Since the uneven effectiveness of our healthcare also requires improvement, reforming the healthcare industry will not be easily achieved. Ultimately, the reform process will require widely acknowledged, public support as the basis for promoting the necessary changes. The governance for NATIONAL HEALTH is purposely structured to warrant the national support needed to reform our nation’s healthcare. The “polycentric governance” concept of Elinor Ostrom for averting a “Tragedy of the Commons” is a guiding focus for the NATIONAL HEALTH Initiative.
CAREER ACHIEVEMENT PLAN
The transformation fostered by NATIONAL HEALTH will need an extended period of time to achieve the full expression of its V I S I O N, MISSION and PRINCIPLES. The eventual outcome following the implementation of this Initiative would be defined by its success in promoting enhanced Primary Healthcare, especially to the extent that it is equitably available to every citizen within their own community. We anticipate that the essential contributors would be the nearly 800 Community HEALTH Forums involving Primary Physicians, public health departments and community hospital systems as they reduce the barriers to enhanced Primary Healthcare within their own communities of @400,000 citizens. Beginning with a District Coalition baseline evaluation, a systematic plan for reducing these barriers would be adopted and the required resources identified by each community to establish their own Community HEALTH Plan, as formulated by its own Community HEALTH Forum.
The most important attribute of enhanced Primary Healthcare will be the responsibility within each clinic to foster a Career Achievement Plan by each member of its staff, especially their Primary Physicians. Currently, the professional commitment necessary to manage the high level of uncertainty associated with Primary Healthcare creates a daily level of conflict resolution that is very difficult for any Primary Physician to endure. Given the breadth and variable depth of unexpected uncertainty characterizing Primary Healthcare, each Primary Physician works at a very different level of emotional, technical and managerial complexity as compared to the other physician specialties. A review of the HEALTH STORIES Sub-Page of the APPENDIX Page offers a description of the people who need an intense level, often daily, of accountability by any physician, especially a Primary Physician. Having a self-renewing process to help each physician structure the priorities for their own professional career will be essential for responding to the intensity required by any of their Caring Relationships, personal as well as professional.
NATIONAL HEALTH would foster a general commitment at all levels of the healthcare industry to support the professional career of the physicians who offer healthcare to our nation’s citizens, especially Primary Physicians. In 1993, Peter Drucker described the importance of improving the business assets represented by the professional personnel within any information based institution. (2) A Career Achievement Plan, annually revised, would be the most important strategy, among many others, for improving the professional assets required for Primary Healthcare.
SUPPORTIVE TRADITIONS
In addition to Primary Healthcare, there are many other institutions in our nation that will need to make a special commitment to actively support NATIONAL HEALTH. The Federal government will need to support the efforts within each state to help sponsor universal healthcare insurance for each of its citizens. Any new Federal requirements for each state to support nationally sponsored Universal Health Insurance must have a reasonable and guaranteed commitment from the Federal budget, especially for those citizens who require an intense level of healthcare for their Complex Healthcare Needs. Without this level of assistance, it would be difficult for any state to also support the involvement of its Department of Public Health in the affairs of NATIONAL HEALTH.
The pharmaceutical industry will need a renewed commitment to excellence and altruism. The essential attributes of product development, marketing and manufacturing will need new priorities based on Trust, Cooperation, and Reciprocity. To forestall price controls, the time-honored business model for pharmaceutical institutions will need revision, especially its unusual profit margin.
Similarly, there are other conflicts of interest that exist at virtually every level of the healthcare industry. In spite of the collaborative efforts of NATIONAL HEALTH, special Federal legislation may be necessary to promote a comprehensive approach to resolving the persistence of pervasive conflicts of interest within the healthcare industry. This applies especially to the co-dependent relationship between the payers of healthcare and the hospital systems devoted substantially to the healthcare of Complex Healthcare Needs. Any pervasive conflict of interest that adversely affects the institutional V I S I O N, MISSION and PRINCIPLES of NATIONAL HEALTH would require the most immediate resolution.
The health insurance industry will need to sponsor innovative funding options for enhanced Primary Healthcare. Certain clinics will likely demonstrate a unique ability to offer effective and efficient health care. It would be helpful to all levels of healthcare for the health insurance industry to identify these clinics as a means to form a less adversarial, suspicious operating character with physicians having the skills to offer and arrange efficient and effective healthcare. The budgetary and actuarial challenges of health insurance require a unique institutional culture for its success. Even if unintended, the industrial face of health insurance companies often implies an adversarial attitude regarding the personal priorities of their “members” and the health professions. For the health insurance institutions, acquiring the skills necessary to express the norms underlying social capital for resolving the social dilemmas occurring for their members and each Primary Healthcare clinic should be an outgrowth of NATIONAL HEALTH.
Last but not least, medical schools have a unique role to assume for the success of the NATIONAL HEALTH Initiative. It is instructive to identify the unique institutional character of a medical school. With one long-enduring exception, virtually every other scholarly endeavor within a university defines its institutional value to society by setting itself apart from the municipal life of society. In fact, it is this separation that best defines those university efforts that are likely to be of most value for a future renewal of the HEALTH Knowledge required for each citizen. As compared to the remainder of any university’s activities except agriculture, each medical school is directly responsible for the healthcare of many citizens with very Complex Healthcare Needs. Importantly, it is the economic activity involved in the research and health care for these Complex Healthcare Needs that defines the identity as well as the financial stability of most, if not all, medical schools. The dominating economic influence of healthcare and research for Complex Healthcare Needs has unintentionally diminished the importance of Primary Healthcare for each person’s HEALTH as a priority within the medical school academic environment. The resultant impact on the priorities for preparing physicians to function as a Primary Physician is profoundly discounting and pervasive, even if unrecognized and unintended.
NATIONAL HEALTH would offer a select group of medical schools the financial support needed to more fully immerse their connection with each clinic’s operational requirements for offering Primary Healthcare within a community of citizens. With its connection to nearly 800 Community HEALTH Forums, NATIONAL HEALTH would have a unique opportunity to sponsor a greater level of active immediacy within each medical school regarding the importance of enhanced Primary Healthcare for the Basic Healthcare Needs of each citizen, community by community.
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Each Forum, as proposed by the community HEALTH Forum Page, would replicate for healthcare reform the provisions established for the Cooperative Extension Service within agriculture, established by Congress with the Smith-Lever Act of 1914. In stark contrast to our nation’s healthcare industry, our nation’s agriculture industry is the most efficient and effective among the developed nations of the world. Meanwhile, our healthcare industry represents the least efficient healthcare industry among the developed nations of the world with undeniable gaps of quality. A new strategy for healthcare reform must progressively promote an active connection by our nation’s medical schools with the front line of Primary Healthcare, much as the Smith-Lever Act has done for agriculture.
PERSONAL HEALTH
Our national health priorities need a counterbalance to the exaggerated level of entitlement that characterizes the expectations of many citizens who seek health care. As a result of these expectations, our nation’s healthcare has become increasingly involved in the healthcare for life-style related HEALTH Conditions. For example, the increasing number of citizens with obesity and its related health problems could be characterized as an epidemic. Historically, there is no specific health insurance benefit for obesity related health services except for bariatric surgery. Truly, this represents the greatest anachronism for healthcare: risky healthcare to solve the adverse effects of a life style problem. Similarly, chemical dependency, profound mental health conditions and homelessness are issues that are very complicated for a Primary Healthcare clinic and inappropriate for a hospital’s Emergency Department. I am aware that an isolated metropolitan community has arranged a community-wide mental health hospital and “emergency” center just for these very complicated health conditions.
To achieve appropriate expectations for our nation’s healthcare, many of our social institutions will need to foster new traditions that demonstrate a connection to the contemporary needs of a healthy life. In the future, effective and efficient health care will require an improved level of self-discipline by each citizen regarding their own health. In short, every citizen will need a renewed commitment to healthy living. As a prerequisite for achieving Stable HEALTH, the basics are certainly well-known: 1) restful sleep, good food, dedicated exercise and mentored courage; 2) meaningful involvement in the needs of the community starting with each person’s own education and employment; 3) participation in a family focused spiritual community as a basis for refining one’s personal values and 4) a long-term commitment to actively support the Caring Relationships originating from within each person’s own Family. To honor the evolving character of our multicultural society, the specific attributes of the basics will vary considerably from person to person. Furthermore, the basics should represent a socially inclusive reconciliation by each citizen as a basis for achieving their own level of “Stable HEALTH”.
The historic roles of certain institutions within our society are undergoing great change, especially churches, neighborhoods, schools and the media. Our nation’s healthcare industry should be included on this list. NATIONAL HEALTH could be viewed as an effort to refocus these changes as a means to improve each citizen’s priorities for healthy living. Hopefully, this would also involve a cohesive effort at all levels of society to promote and support NATIONAL HEALTH. Even with this national priority, “Stable HEALTH For Each Citizen” still begins with a need to recognize that restful SLEEP, good FOOD, dedicated EXERCISE and mentored COURAGE are the essential basics for the HEALTH of every citizen.
SOCIOECONOMIC ADVERSITY
Importantly, this NATIONAL HEALTH Initiative is also based on a the proposition that our nation’s healthcare industry has the ability to achieve a very high level of uniform quality. The central problems currently creating the uneven levels of quality are 1) the socioeconomic determinants for which Primary Healthcare is variably unable to offer equitably available and ecologically accessible health care to each citizen, especially for those citizens who are infants, homeless or disabled and women during a pregnancy and 2) the absence of any nationally sanctioned institution to uniformly promote enhanced Primary Healthcare for the Basic Healthcare Needs of every citizen. The socioeconomic determinants range from the special health needs of almost any citizen to the group attributes of an entire community. A single mother without a supportive Extended Family represents the individual extreme. The children who have lived in a section of Omaha with yards and playgrounds heavily contaminated with lead represents a community extreme, largely resolved eventually by the Environmental Protection Agency.
Since 1969, the technical advances in the character of our nation’s healthcare have evolved very rapidly. The ability of our nation’s healthcare to implement these technical advances has not adapted as rapidly. The outcomes produced by this disparity is the rapidly worsening the cost of our healthcare. Among many other concerns about our nation’s healthcare, its most troublesome attribute is that it is terribly inefficient. Even though there are other causes, the main cause for the inefficiency of our healthcare industry is its inability to responsively form a Caring Relationship with each citizen as the basis for promoting “Stable Health.” This deficit disproportionately affects our citizens who suddenly and unexpectedly require health care for very Complex Healthcare Needs.
VOLUNTARISM
NATIONAL HEALTH will improve adequately funded Primary Healthcare through a nationally defined certification process to achieve a sustained improvement of its skill-set. Each Primary Healthcare clinic maintaining a HEALTH SECURITY certified status would be eligible for a higher level of financial reimbursement. Part of the certification process would emphasize the responsiveness of a clinic’s ability to foster the Caring Relationships that are necessary for any citizen to obtain equitably available healthcare that is ecologically accessible. A renewed focus on our nation’s healthcare obligation to each citizen who is an infant, disabled or homeless as well as any woman during a pregnancy would be a very important attribute of success by NATIONAL HEALTH.
As an institution, the success of NATIONAL HEALTH would be a reflection of its collective intellect as it fosters enhanced Primary Healthcare for all citizens. But for the individual citizen, the success of NATIONAL HEALTH would be the result of the collective will as identified by the Caring Relationships offered by a Primary Healthcare Team to every citizen. The Design Principles for managing a common-pool resource, as in the portion of our economy available for health spending, must be applied to all levels of our nation’s healthcare industry as a strategy for harvesting the intellect of our nation to offer its application for the will of each citizen to achieve Stable HEALTH through the Survival Commons of their own community.
