d e c e n t r a l i z e d g o v e r n a n c e
N A T I O N A L H E A L T H p r o p o s a l
6 pages — 1 —
INTRODUCTION
“Never doubt that a small group
of thoughtful, committed citizens can change the world;
indeed, it’s the only thing that ever has.”
Margaret Mead (1901 – 1967)
“We shape our buildings, and afterward our buildings shape us.”
Sir Winston Churchill (1894 – 1965)
“What must be done to make the difference is known. Plenty of isolated examples exist
to illustrate the improvement of care achieved by teams or organizations, and each week
new evidence is published giving fulsome testimony to that fact. The challenges
to health care will not disappear; ‘how can we’ hesitancy needs to be replaced
with ‘why not’ energy. Only courage and properly constructed large-scale change
will make a difference in changing health care.” (Oldham 2009)
Sir John Oldham (1947 – )
The second and third quotations cited above come from the UNITED KINGDOM, a nation with a geographic area that is 2/3 the size of the State of Nebraska but a national population that was 33 times larger durirng 2020. Sir Winston Churchill is the author of the second quotation. It is taken from a speech he gave on October 28, 1943, to the House of Commons. Two years earlier, the bombing during World War II had destroyed its Chamber. On plans to rebuild the Chamber, he stressed the need to continue the smaller arrangement of the Chamber in its original form as a means to support their traditional style of debate. Substituting “traditions” for buildings in the quotation from Winston Churchill offers a perspective applicable to our nation’s healthcare. Our healthcare needs a New Strategy to reshape its traditions. We can no longer depend on the current status of our nation’s historic traditions to promote the transformation that is required. It is also likely that our basic Traditions are fundamentally valid and do not require replacement by starting any totally New Traditions.
The third quotation is also from England. It concludes a COMMENTARY published in the March 4, 2009 edition of the Journal of the American Medical Association. The expertise of Doctor Oldham as well as others with experience in the management of large system change will be necessary for the implementation of NATIONAL HEALTH. All in all, we “USA North Americans” tend to forget about the gift to our nation’s Traditions that came from the heritage of England, especially its rule of law as established initially by their Magna Carte in 1215, now 1000 years ago.
The two quotations from the UNITED KINGDOM, cited above, are another example of the English heritage that is still relevant today for all the developed nations of the world, especially our own. The first quotation by an American anthropologist alludes to the importance of beginning any new, Human Dignity, associated institution with Goals that aim to achieve a magnificent benefit.
GLOBAL TASKS
The initial operational status of the NATIONAL HEALTH Proposal uses the five Institutional Global Tasks as a basis to define and provide a structure for achieving its GOALs. These Global Tasks for NATIONAL HEALTH wound inform the initial Policies and Procedures for achieving the responsibilities established by the Congressional Charter for NATIONAL HEALTH. The initial compendium of Institutional Tasks are not necessarily sequentially ordered. However, the specific tasks associated with each Institutional Global Task will uniquely interact individually to augment the other four Institutional Global Tasks. An underlying commitment to the sociality norms of Trust, Cooperation, and Reciprocity will induce an orderly focus on the interdependent global tasks necessary to achieve the ‘VISION’ of NATIONAL HEALTH, viz.: Stable HEALTH For Each Resident Person. The ‘VISION’ for NATIONAL HEALTH defines the ultimate benefit to be achieved by NATIONAL HEALTH by our nation’s Population Health and its Healthcare. In addition, the five Global Institutional Tasks will require the ‘VISION’ as a means to help unify and focus their interacting decision processes, especially in the absence of a clearly pre-situationally established precedence or an approved Policy or Procedure.
Using the combined five Global Institutional Tasks as a format for Congressional legislation, the Sub-Pages of the NATIONAL HEALTH Proposal Page could represent a template for the NATIONAL HEALTH Act of 2023. Start by clicking on the “ORGANIZE Governance” Sub-Page. After reviewing this Sub-page, the scope of the New Strategy and its associated FOUR NATIONAL PROJECTS will begin to have greater meaning, i.e., make sense. The remaining four Global Task ‘Sub-Pages’ are equally concise but much less intense.
Eventually, the combined effort of 90 Members, 500 Associates, and 8,000 Advocates working collaboratively to achieve a unified ‘VISION’ will improve the PRIMARY HEALTHCARE of each resident person, community by community. Secondly, the formation of NATIONAL HEALTH could be a valuable benefit for our nation as we encounter the worldwide community in the future. A successful NATIONAL HEALTH should intentionally improve our nation’s level of social cohesion, community by community, that would serve to restore our nation’s languishing sense of purpose and connection with our nation’s heritage. Now is the time to follow the admonition of the anthropologist, Margaret Mead, cited above, to improve Stable HEALTH For Each Person, community by community.
S U B – P A G E S
ORGANIZE GOVERNANCE
Unexpectedly, it is possible to assign each state and protectorate to one of nine separate and mostly contiguous clusters with each having a nearly equal number of resident persons: 37 million. To constitute the basis for the governance of NATIONAL HEALTH, each of the nine clusters would each select one Member on the Board of Trustees. This Sub-Page describes the continuing formation of a fully operating Board of Trustees and the structure of its governance. It also describes one alternative process for maintaining an experiential “front-line” perspective by the Board of Trustees during their sequential 9-year replacement cycle. As a Sub-Page of the GOALs Page, I describe a process for selecting the Initial Membership for the Board of Trustees for instituting NATIONAL HEALTH. Presumably, a similar selection process would be included in the Congressional Charter for NATIONAL HEALTH.
One Board of Trustees and nine Regional Councils with each Regional Council connected by 900 Community HEALTH Forums. Together, this represents the overall governance structure for NATIONAL HEALTH. Basically, the two upper levels would focus on defining the Policy and Procedures for the leadership Tasks and the lowest levels would focus on the implementation Tasks at the community level. In effect, each Community HEALTH Forum, consisting of 9 Advocates, would be initiated and supported through local initiatives as mentored by their respective Regional Council. The formation of the Community HEALTH Forums would evolve according to an Operational Statement approved by their respective Regional Council under the authority of a Policy authorized by the Board of Trustees. — 3 —
Each community’s Forum would have the responsibility to promote the locally identifiable stakeholders necessary to assure that Primary Healthcare is equitably available to every resident person within their community. Initially, each Forum would evaluate the Primary Healthcare that is available to its approximately 400,000 resident persons. Using a projected ratio of 1 Primary Physician per 1,500 resident persons and 4-FTE primary Physicians per clinic, approximately 75 HEALTH SECURITY certified Primary Healthcare clinics would eventually represent an average baseline requirement for the Community HEALTH Plan of each Forum. Through an evolving collaborative analysis, the annual Community HEALTH Plan would be formulated by each Forum from the involvement of its community’s most broadly identifiable and relevant HEALTH stakeholders. Importantly, this Plan would begin by understanding the current, locally established sources of Primary Healthcare before considering any need for new or incrementally rearranged, current sources of new Primary Healthcare. Eventually, these sources of Primary Healthcare would become HEALTH SECURITY certified to qualify for their augmented financial support. This would become more appealing if developed through a memorandum of understanding that initiated improved financial support immediately in return for steadily satisfying a stepwise plan to achieve full certification by a Primary Healthcare clinic.
As equitably available as well as ecologically and culturally accessible enhanced Primary Healthcare becomes increasingly assured for each community’s resident persons, each Forum would then focus on the prominent disruptive processes that adversely affect the Population HEALTH of their community, including its disaster preparedness.
PURSUE ‘V I S I O N’
The ‘V I S I O N’ will become increasingly possible when enhanced Primary Healthcare becomes equitably available to every resident person. Three National Projects will be required to reach this GOAL. First, a nationally sponsored, Regionally coordinated and locally adjustable, HEALTH benefits plan will be defined for all resident persons as a basis for their reimbursement by any nationally coordinated healthcare insurance plan. A nationally initiated Primary Physician Medical Education Plan will be defined based on the involvement of the appropriate national stakeholders. This Plan will assure the career-long availability of Primary Physicians for each community. The third National Project will institute a Regionally managed certification process to assure the minimal operating characteristics of enhanced Primary Healthcare as a basis for its augmented capitalization by all healthcare insurance plans.
The ultimate reality may require 10-15 years to be fully implemented. For a successful outcome, a 10-year “Mission to the Moon” start-up phase would trigger the basis for a permanently evolving paradigm renewal commitment. This Sub-Page identifies these three national projects for supporting the growth of enhanced Primary Healthcare that is equitably available to each resident person, community by community.
BUILD COMMUNITY
There are two special attributes of the NATIONAL HEALTH project. The first attribute refers to the Three National Objectives that focus on the national priorities necessary to permanently assure that equitably available Primary Health Care is offered to each resident person, community by community. The second attribute refers to the local implications of these Three National Projects and represents a new strategy for healthcare reform.
The 50 States and our protectorates may be generally divided into the Northeast, Southeast, and West sections of the U.S.A. The governance of NATIONAL HEALTH, as proposed, represents an opportunity to form a means to assure that the Three National Objectives and their specific needs are balanced among the three Super-Regions and their respective 3 groups of States. Simultaneously, the traditions of the individual states must continue to be acknowledged and respected among all of these States. The opportunity for NATIONAL HEALTH to slowly shape the basis for our Nation’s future scenario of lasting healthcare reform may represent its most important GOAL. It begins community by community.
The second set of special attributes of the NATIONAL HEALTH project refers to the formation of nearly 800 locally initiated and funded, collaborative Community HEALTH Forums to champion the full development of our nation’s Primary Healthcare needs. Each community for NATIONAL HEALTH would represent approximately 400,000 resident persons as a portion of one county or several contiguous counties. A Community HEALTH Forum would begin by defining its own Survival Commons (viz, an augmented safety net) as a means to improve their community’s resilience from the disruptive processes uniquely encountered daily by groups of persons within the municipal life of their own community. The Advocates for each Community HEALTH Forum would be resident persons selected from within their own community. The initial Advocates would be selected by a cluster of these locally representative citizens who express a connection with their community’s Stable HEALTH and represent the citizen networks of their NATIONAL HEALTH designated community. The preliminary nominating, community collaborative would implement a collective action strategy for this purpose. The NATIONAL HEALTH Associates from each respective District Council would help mentor this initiating formation process.
The generational affairs of each Community HEALTH Forum may be the most important attribute of NATIONAL HEALTH. Unlike all the other developed nations of the world, we have no currently authorized and implemented plan to improve the social cohesion and its HEALTH attributes within each community. This refers to the belief that trustworthy persons exist throughout our nation’s communities. Good population studies indicate that a community’s self-reported HEALTH is related to its perceived level of TRUST and that a higher level of TRUST is subsequently related to a better level of self-reported HEALTH. It is known as a reverse causality phenomenon. Our nation’s social cohesion decline is an underlying cause of our nation’s worsening maternal mortality, child neglect/abuse, adolescent suicide/homicide, homelessness, mass shootings, sedative overdose mortality, mid-life depression/disability, and decreasing longevity at birth.
MANAGE RESOURCES
The Charter for NATIONAL HEALTH will include a fixed Federal contribution for its financial resources and a requirement that the new institution could never be connected with the direct or indirect distribution of economic assets for the health care of any person or group of persons, except as a group health insurance benefit for its Associates. The Charter will also mandate a transparent level of stewardship for these resources as defined by its institutional PRINCIPLES.
A steadily improving level of Primary Healthcare that is justly efficient and reliably effective will be required to bring about the priorities required to improve each resident person’s HEALTH, especially for maternal HEALTH. It could be argued, that Human Dignity is more important than its Resources, even though the origins of NATIONAL HEALTH occurred as a result of the low-level efficiency associated with our nation’s healthcare. One short sentence in a 2010 NEJM Editorial sums up the priorities most succinctly. Referring to the health care for Tuberculosis and a recently introduced technical advance in its diagnosis, the authors said: “Health systems must be strengthened so that patients do not delay in seeking care and have prompt access to appropriate treatment once they receive a diagnosis.” (30) A remake of the entire healthcare industry will be required for this goal, beginning with its Primary Healthcare. Our nation’s maternal mortality ratio is merely the most succinctly-monitored measure of its overall effectiveness. For Human Dignity, maternal health may also be the best measure of our Nation’s dedication to reducing the broad range of adversities, commonly occurring in patterns of disruptive processes that cause Unstable HEALTH for too many resident persons.
As a simultaneously enacted congressional contribution, our nation’s ACA 2010 (aka Obamacare) will need to be amended to improve its applicability to all resident persons. Also, it will require an appropriate design for distributing its risk structure to more carefully allocate its annual health spending to the various segments of its distribution. It should provide a financial structure for the risk-managment accountabilities throughout our nation’s healthcare industry, especially the augmented reimbursement of Primary Healthcare that is HEALTH SECURITY certified. Rather than “bottom line” risk-sharing, it could be connected with alternative forms of behavioral economics, especially during its initial implementation. Ultimately, substantial progress for lowering national health spending as a portion of the GDP could be tied to an increased level of Federal financial support for medical education, especially when NATIONAL HEALTH achieves is goal of 13% GDP health spending.
DEVELOP SKILLS
Importantly, the structure of NATIONAL HEALTH offers a 36-year opportunity for a resident person to fulfill a national leadership contribution to our national heritage: four administrative levels with a 9-year contribution at each level. Realistically, it is unlikely, but remotely possible, for someone to make such a commitment. The knowledge and understanding of change would be profound. To the extent it is possible within the leadership pyramid of NATIONAL HEALTH, it would be a remarkable achievement for anyone to make such a commitment, especially as a Primary Physician. With an involvement for more than 9 years by increasing numbers of Members, Associates, or Advocates, it is likely that the associated accumulation of social capital would have a strong impact on promoting the stability of each community’s Survival Commons. Such is the over-riding theme for the NATIONAL HEALTH Page and its Sub-Pages.
The NATIONAL HEALTH Initiative includes a proposal to implement a self-driven Career Achievement Plan by each of its Members, Associates, and Advocates. The refinement of this model could serve as the basis for the professional character of Primary Physicians as proposed by their Career Achievement Plans. It is likely that the widespread occurrence of “burn-out” among physicians reflects the absence of this professional attribute within our nation’s healthcare industry.
Finally, it is not possible to define every Task necessary for the successful functioning of an institution. Beginning with the initial Meeting of its Board of Trustees, a set of PRINCIPLES will be necessary as a guide for the correct action when an Operational Statement does not exist OR conflict arises between competing Operational Statements. Any new institution with 4 layers of governance that is spread out over 3.5 million square miles at its base will inevitably encounter this phenomenon, especially as aggravated by ethnographically related cognitive dissonance. These PRINCIPLES at the beginning could be as follows: ALTRUISM – TRUST – COOPERATION – RECIPROCITY – EXCELLENCE. — 5 —
This page has the following sub pages.