* MANAGING a COMMONS

averting a “Tragedy of the Commons”

The DESIGN PRINCIPLES For

M A N A G I N G a C o m m o n s

As APPLIED To HEALTHCARE REFORM

INTRODUCTION

For any group of people, the participation hypothesis states that

“… significant changes in human behavior can be brought about rapidly

only if the persons who are expected to change

participate in deciding what the change shall be

and how it shall be made.”

Herbert A. Simon ( 1926 – 2001 )

“Any group that attempts to manage a common – pool resource

for optimal sustainable production must solve a basic set of problems

in order to create an institution for collective action;

( e. g. , aquifers, judicial systems, pastures )

there is some evidence that using a small set

of design principles in creating these institutions

can help overcome these problems.”

Elinor C. Ostrom ( 1933 – 2012 )

Herbert Simon was a faculty member at Carnegie Mellon University and an early founder of Artificial Intelligence. In 1978, he received a Nobel Prize in economics for his research on decision processes within institutions. As formulated by Professor Simon and cited above, the Participatory Hypothesis should be a recurring attribute of the new strategy widely emphasized throughout the Blog.

Consistent with the Participatory Hypothesis, we propose that the driving “engine of change” for healthcare reform would, most powerfully, arise from within each community from coast to coast. In essence, NATIONAL HEALTH would be committed to promoting community based groups with the skills to successfully over-come the deficits within their own community’s COMMON GOOD as the basis for promoting an improved level of efficiency and effectiveness withi our nation’s healthcare. The outline below, formulated initially by Elinor C. Ostrom, can be found on the http://www.cooperationcommons.com web site. Its use, on this Sub-Page, defines the early attributes of NATIONAL HEALTH that will assure an enduring and augmented enhancement of the Social Capital within every community. Ultimately, this strategy could be the best means to improve the HEALTH of each citizen, community by community.

A “common-pool resource” and a “commons” are terms that refer to the same concept. For healthcare reform, its common-pool resource can be defined as the most “appropriate portion” of our nation’s economy that can be allocated to the individual HEALTH needs of all citizens: equitably, ecologically, justly and reliably. Recognizing our nation’s commitment to world-order and to our nation’s autonomy, the appropriate portion for healthcare is initially most likely to represent 13.0% of our national economy. Given its current cost of 18%, 13% of the national economy would represent a 28% decrease in the portion of our nation’s economy devoted to healthcare. Rather than specific measures to ration healthcare unit costs, NATIONAL HEALTH represents a strategy to eventually limit further increases in health spending to between 0.25% & 0.5% less than economic growth.

Spread out over a period of 10 years, a declining use of our national economy for healthcare, by itself, would generate a secondary spurt in the growth of our national economy. In effect, a very strong commitment at the beginning of healthcare reform might be the most important means to minimize any occurrence social and economic turmoil during the first 10 years of the new strategy for healthcare reform.

For healthcare reform, the financial projections do not necessarily mean an absolute decrease in a nation’s annual healthcare spending. Its growth should progressively be less than economic growth for 5-10 years. Subsequently, it could return to a level that is commensurate with economic growth. Certain low levels of improved efficiency might be achieved quickly by the attention focused on certain areas of inefficiency, such as, reduced after hours use of Emergency Department use from a more responsive level of medical TRIAGE by Primary Physicians, advanced use of community-wide narcotic use contracts, state by state adoption of “best practices” for authoring medical tort reform, or the group-practice adoption of a Primary Healthcare Formulary to guide improved medication use. Eventually, our nation’s annual healthcare spending should never increase more than our nation’s annual economic growth.

Next, what is it that is known about the attributes of collective action and its capacity to successfully manage a commons? Given her extensive list of scholarly publications, it is easy to focus solely on the academic career of Professor Ostrom. In reality, there are many other political economists who have contributed to our knowledge underlying how the appropriators, i.e. health care providers, of a commons can successfully collaborate to access their commons without damaging its stability. Professor Ostrom began with a commitment to apply all that was known about common-pool resource (CPR) allocation problems as a basis to define the attributes for the successful management of any CPR. Along with the research of many colleagues, Professor Ostrom proposed seven Design Principles as the basis for proposing any new institution with an intent to prevent or resolve a “Tragedy of the Commons.” They are listed below along with a brief description of how NATIONAL HEALTH would function to successfully reform our nation’s healthcare.

“THE EVOLUTION OF INSTITUTIONS FOR COLLECTIVE ACTION”

A. “Clearly defined boundaries. The identity of the group and the boundaries of the shared resource are clearly delineated.”

1. Congressional Charter —

a. State by State Commitment — The Initiative would require the active support by each State’s legislature. The regulatory provisions for each State’s Department of Insurance should include the authority to accommodate the NATIONAL PRIMARY HEALTHCARE BENEFITS PLAN as they regulate the performance of their state’s health insurance industry. Nationally, this PLAN would also apply to Medicare, Medicaid, Department of Defense, Native American Health Services, Comprehensive Healthcare Centers, and Correctional Services (at all levels of government).

Similarly, each State’s Department of Health must also have the authority to participate in the affairs of a District Coalition and its Community HEALTH Forums functioning in their State. The Congressional Charter should prohibit the involvement of NATIONAL HEALTH with any non-participating State beginning 11 or more years after the initial Meeting of its Board of Trustees. Additionally, a two stage process could terminate NATIONAL HEALTH at any time.

b. Funding — NATIONAL HEALTH would be granted annual funding for its affairs based on an amount equal to $1.00 per citizen per year, annually adjusted for inflation, beginning with the initial Meeting of the Board of Trustees. Beginning eleven years after the initial Meeting, the Federal funding would only apply to the number of citizens represented by the participating States. The Congressional Charter would prohibit the use of these funds for both 1) any direct health care other than as a health insurance benefit for the Associates (i.e., employees) of NATIONAL HEALTH and 2) the operational expenses of any Community HEALTH Forum other than for the training of its Advocates or technical assistance by their District Coalition. Should NATIONAL HEALTH be terminated by Congress, any remaining assets would be returned to the Federal government.

c. Federal and State government regulations — The processes of change for Primary Healthcare should uniformly benefit each citizen throughout their lifetime including Veterans, native Americans, under-served citizens benefiting from a Community Health Center, residential institutions (e.g., prisons and nursing homes) as well as the other citizens of each State, the District of Columbia and our nation’s protectorates. The Congressional Charter would specifically provide a means for NATIONAL HEALTH to amend Federal regulations with a due process with Presidential and Congressional oversight. This process should immediately provide 1) guidance for managing the conflicts of interest occurring among the Advocates of each Community HEALTH Forum and 2) the appropriate release of de-identified national maternal mortality ratio data to each District Coalition. The issue of supportive State by State regulatory concurrence could be managed by terminating a State’s involvement for persistent lack of regulatory support.

[ COMMENT: State by state maternal mortality data was not available to the public between 2006 and 2016. Eventually in late 2016, a medical journal published a report for the aggregate maternal mortality ratios, State by State, from 2005 through 2014. An analysis of the annual national data for 2000 thru 2014 was reported separately in the same edition of the medical journal. For 2000 thru 2014, the national maternal mortality ratio increased annually from 18.8 to 23.8 maternal deaths per 100,000 live births. The change represented a 1.58% worsening, compounded annually. Assuming a nearly constant annual occurrence of 4 million live births annually, the change represents: @750 maternal deaths in 2000 and @950 maternal deaths in 2014. Please note that 20% of the advanced/developed nations have a maternal mortality ratio of less than 6 deaths per 100,000 births. We would need to reduce our nation’s maternal mortality to <240 deaths annually to reach that level.

I have encountered an effort, citation lost, to monetize the loss of social capital to a family as a result of a mother’s death. One estimate used a certain logic that a family would lose the monetized equivalent of $500,000 worth of social capital with the death of its mother. I suggest that if the family were members of a rural Alaskan native American tribe, it would be a lot more. Maybe that’s why the maternal mortality ratio is always so low in Alaska. Its a Social Capital issue, as in the role of women within their Family Traditions has a much higher importance for their communal survival. ]

d. Governance — The Congressional Charter would include provisions for the initial selection of the top two levels of governance for NATIONAL HEALTH. Within three years of the initial Meeting of its Board of Trustees, a permanent selection process for the Board of Trustees and its nine Regional Councils would be initiated by the Board of Trustees. A preliminary proposal to form the initial GOVERNANCE of NATIONAL HEALTH can be found elsewhere on the Blog. The Board of Trustees and each Regional Council would each have nine Members appointed with a similar array of regional vested interests.

The second level of governance would require the selection of nine Regional groupings of contiguous States, each Region with a roughly equal population. The total 2016 census population for each Region appears before the listed State groupings listed below. The mean is 36.46 million citizens per Regional Council with one standard deviation in the variation of the population among the regions representing 2.37 million citizens. The Census Bureau estimated that the total population for 2016 was 322,762,018.

Region 1 EAST —————————— 32.98 – Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania and the Protectorates of Puerto Rico and the U.S. Virgin Islands

Region 2 NORTH EAST ————— 34.47 – Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island and Vermont

Region 3 SOUTH EAST ————— 35.66 – Georgia, North Carolina, South Carolina, West Virginia and Virginia

Region 4 CENTRAL ———————- 35.42 – Indiana, Kentucky, Missouri, Ohio and Tennessee

Region 5 SOUTH CENTRAL ——– 36.13 – Alabama, Arkansas, Florida, Louisiana and Mississippi

Region 6 NORTH CENTRAL ——– 37.16 – Illinois, Iowa, Michigan, Minnesota and Wisconsin

Region 7 WEST —————————— 39.25 – California

Region 8 SOUTH WEST ————— 40.79 – Arizona, Oklahoma, New Mexico and Texas

Region 9 NORTH WEST ————— 36.27 – Alaska, Colorado, Hawaii, Idaho, Kansas, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming and the Protectorates of the Samoan Islands and Guam

2. Board of Trustees

a. Members 9 – Three Primary Physicians, Two Specialist Physicians, One non-Physician mental health practitioner, One Public health practitioner, One health ethics professional and One health economist professional

b. Core responsibilities –

i. Establish the national basis for the capability of nearly 800 communities, each representing @400,000 citizens, to use collective action as the means for promoting the availability and accessibility of HEALTH SECURITY certified Primary Healthcare for each citizen, to assure that the social adversities affecting the HEALTH of the local community are given the benefit of collective action for their improvement AND to reassess annually a comprehensive MASTER DISASTER MITIGATION PLAN;

ii. Engage as many alternate pathways as possible to promote a national healthcare industry that is more efficient as in reducing its cost to <13.0% of the national economy and more effective as in reducing our nation’s maternal mortality ratio to 5 deaths per 100,000 live births annually by a special emphasis on career long pre- & post- graduate medical education for each Primary Physician and their respective Primary Healthcare Teams; AND

iii. Maintain a ten-year cycle of renewal of the Congressional Charter in consultation with Congress to reassess the envisioning statements for the affairs of NATIONAL HEALTH to maintain the capability for the future requirements of national healthcare reform.

[ COMMENT: In 2017, our nation’s health spending represented 18.0% of the national economy and was projected to worsen. That same year, the maternal mortality ratio was an estimated 25.0 deaths per 100,000 live births. ]

iv. Maintain Operational Statements for the governance of NATIONAL HEALTH using an approval process according to Robert’s Rules of Order Newly Revised, current edition, and compiled based on the best practices described by Chapter 5, of the book UNDERSTANDING INSTITUTIONAL DIVERSITY, written by Elinor Ostrom, Ph.D. and published in 2005.

3. Regional Councils — 9

a. Members — (same professional constellation as the Board of Trustees)

b. Core responsibilities of each Council —

i. Collaborate with the Board of Trustees in an advice and consent relationship for the over-all governance of NATIONAL HEALTH to maintain regional accommodations within its operational affairs,

ii. Establish the Regional governance basis for their 9 District Coalitions to provide technical assistance to the local community formation of @81 Community HEALTH Forums,

iii. Mediate the National leadership required to support the District Coalition opportunities to promote local needs within the NATIONAL PRIMARY HEALTHCARE BENEFITS PLAN, NATIONAL PRIMARY PHYSICIAN EDUCATION PLAN, and NATIONAL HEALTH SECURITY CERTIFICATION PLAN, and

iv. Monitor District Coalition progress for collecting Hospital Utilization and Maternal mortality incidence data, Community Disaster Mitigation Plans, and Community HEALTH Plans AND produce monthly summaries for the Board of Trustees along with a Regional Assessment.

4. District Coalitions (9 constituted by each Regional Council) 81 — Each Coalition would cover contiguous counties of one state, or rarely two states, within a single Region, each Coalition representing @ 4 million citizens.

a. Members – 9 for each District Coalition — Each Member would be selected according to its respective Regional Council Policy.

b. Core responsibilities — Each District Coalition would adapt to local conditions and needs as a basis to support the formation of 9 or more FORUMS. This responsibility would also include the authority to terminate a FORUM in case of anti-trust related activities or lack of progress. The national monitoring responsibility of each District Coalition would focus on *) the total number of maternal deaths occurring annually for their @4 million citizens, *) the monthly hospital utilization for each Community HEALTH Forum by the citizens residing within their individual boundaries and *) technical assistance for Advocate training, Forum working affairs (annual reports, FORUM administrative sustainability, and Community Personal Survival Plan progress within their community’s COMMON GOOD.).

[ COMMENT: As of October of 2016, there were three “State by State” data sets for their respective maternal mortality ratios: 1982-1996, 2001-2006 and 2005-2014. Among these three data sets, the States listed among the best cluster of maternal mortality ratios occurred for Alaska 3 times, Massachusetts 3 times, Maine 2 times, Minnesota 2 times and 11 other states 1 time. Among these same 3 data sets, the States listed among the worst cluster of maternity mortality ratios occurred for Mississippi 3 times, Georgia 3 times, New York 2 times, South Carolina 2 times, Oklahoma 2 times, New Mexico 2 times, New Jersey 2 times, Louisiana 2 times, and 7 other states 1 time.

As of February of 2018, there has been no systematic analysis of why some States regularly do well and some do not. The best analysis is still the AMNESTY INTERNATIONAL USA report released on-line in 2000. For many reports on maternal mortality, the long-standing lack of equitably available and ecologically accessible, enhanced Primary Healthcare, community by community, is a recurring theme. ]

5. Community HEALTH Forum (9 or 10 formed by each of the 81 District Coalitions) @800 – Each FORUM would usually represent one or more contiguous counties within one State and represent @100,000 – 500,000 citizens.

a. Membership: 9 Advocates — Each Advocate would be selected according to a Policy of its respective Regional Council, as Vested by its District Coalition.

b. Core responsibilities — Each FORUM would use collective action as a means to establish a Community HEALTH Plan for assuring the equitable availability of HEALTH SECURITY certified Primary Healthcare for each citizen. The Community HEALTH Plan would also monitor locally initiated collective action projects to improve the over-all HEALTH of their community and its community’s connection with National Disaster preparedness planning. The monitored collective action projects would include local efforts to optimize their community’s Common Good.

6. Primary Healthcare clinic – 1 or more, full-time, Primary Physician Teams that are eventually HEALTH SECURITY certified to be eligible to participate in a State’s health insurance market. For each FORUM, a population of 400,000 citizens would require 70-100 Primary Healthcare clinics, each staffed with approximately 3 full-time physicians. This would be widely variable given local HEALTH risks, social capital prevalence, poverty levels and population age distribution.

The availability of Primary Physicians is a particularly precarious problem. The historically insufficient “capitalization” of Primary Healthcare, the lack of a Family Medicine post-graduate training program at nearly 1 out of every 15 post-graduate medical education program and the poorly recognized importance of Primary Healthcare for Population Health within the healthcare industry, together and separately, contribute to the current deficiencies of Primary Healthcare.

B. “Proportional equivalence between benefits and costs. Members of the group must negotiate a system that rewards members for their contributions. High status or other disproportionate benefits must be earned. Unfair inequality poisons collective efforts.”

1. Board of Trustees –

a. OPERATIONAL STATEMENTs for the NATIONAL PRIMARY HEALTHCARE BENEFITS PLAN would include provisions by one or more isolated FORUMs for the temporary, or permanent, use of a special covered procedure to recognize local and substantial, even if temporary, local health risks to ameliorate the risk or occurrence of a HEALTH Condition associated with substantial loss of Stable HEALTH. These provisions might include many dimensions for actuarial stability, responsive implementation as well as for the related scientific, economic and out come assessments. Temporary Benefits for reimbursement should be defined and implemented within 6 weeks of a FORUM request, including retroactive coverage where appropriate.

[ COMMENT: A perfect example of this provision occurred in Flint, Michigan with its water supply lead poisoning. There was a need to achieve wide spread screening for heavy metals using a filter paper means to easily collect using a few drops of blood and submit for highly accurate screening. Concurrently, it is the best and least expensive means for normal screening of infants and toddlers of abnormal exposure to environmental lead.]

b. OPERATIONAL STATEMENTs for monitoring the patterns of healthcare for citizens who may be receiving services for experimental healthcare and reimbursed directly or indirectly by a source of economic assets devoted to benefits covered by standard health insurance. There may be instances whereby services were reimbursed not covered by other definitions, such as a third party (as in Workers Compensation or other liability sources). For NATIONAL HEALTH, this would apply most importantly to Primary Healthcare. Most of the instances otherwise would apply to Complex Healthcare Needs for which the individual economic sources would be involved. On the other hand, the overall problem should be ultimately monitored by one semi-autonomous institution, such as NATIONAL HEALTH. For national affairs, the Board of Trustees would maintain contact with government at all levels and scales.

2. Regional Councils – Broad collaboration to reconcile notifications for temporary Benefit needs from one or more District Coalitions for ultimate action by the Board of Trustees, thoroughly and expeditiously. For these actions, public transparency for the decision process will occur for the “collective action” process.

3. District Coalitions – Receive initial contact and use Operational Statements to forward notifications to respective Regional Council. Maintain contact with local providers and FORUM persistently.

4. Community HEALTH Forums (FORUMs) – continuing contact with local Primary Physicians and responsiveness with community citizens for access to their District Coalition especially for clarification of Experimental Health Care.

5. Primary Healthcare – The eventual sub-division of Primary Healthcare for specialized patient populations will be recognized. This currently occurs for residential citizens who are incarcerated or require nursing home services. It also occurs for the Native American tribal units, the Active Military and the Veterans Administration. Segmentation might be appropriate given payment mechanism, but any HEALTH SECURITY certification should eventually apply to all segments.

C. “Collective-choice arrangements. Group members must be able to create at least some of their own rules and make their decisions by consensus. People hate being told what to do but will work hard for group goals that they have agreed upon.”

1. Board of Trustees –

2. Regional Councils –

3. District Coalitions –