community-centric
A R A T I O N A L E
for improving a nation’s POPULATION HEALTH
and its HEALTHCARE
BEGINNING
all together
with a UNIFIED LEXICON.
9.0
INTRODUCTION
“Consideration for others is the basis
for a good life, a good society.”
Confucius (551 – 479 BC)
“I shall pass this way but once;
any good that I can show to any human being, let me do it now.
Let me not defer nor neglect it, for I shall not pass this way again.”
Etiene de Grillet (1773 – 1855)
“The language of citizenship suggests
that self-interests are always embedded in communities of action and
that, in serving neighbors, one also serves oneself.”
Benjamin R. Barber (1939 – 2017)
“I’ve 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)
“Never doubt that a few committed people
can change the world. In the end,
it’s the only thing that ever has.”
Margaret Meade (1901-1978)
Before getting started, please take a moment to read again the quotations cited above. As represented by these authors, their views of each person’s lifelong survival are similar to my own. Do you also share their view of life? If so, you’ll probably agree with the next sentence about our nation’s healthcare. The current strategy to reform our nation’s healthcare is unlikely to improve the Primary Healthcare offered for the basic healthcare needs of every community’s resident persons. This basic healthcare is often hard to locate within a community or difficult to use because of its inequitable payment systems, the travel barriers to its location, or the need to pass through adverse ecologic and cultural ‘steps and doors’ to benefit from its services.
For truly lasting healthcare reform, any new ‘nationally sanctioned’ strategy must first promote ‘enhanced’ Primary Healthcare that is equitably available by every resident person within the Survival commons (aka augmented safety net) of their own community. Most of the world’s developed nations have their own ‘nationally sanctioned’ strategy to assure the equitable availability of ‘enhanced’ Primary Healthcare for each of their resident persons, community by community. The United States does not.
The deficiencies of this priority contribute substantially to the failure of our nation’s healthcare reform for improving our nation’s Population Health as well as the cost and quality of their healthcare. For healthcare reform, I use the words ‘nationally sanctioned’ to mean locally initiated, community-sponsored, regionally promoted, and nationally instituted. And, I use the word ‘enhanced’ to mean that this primary Healthcare should offer enduring, caring relationships as the basis for promoting ‘Stable HEALTH For Each Resident Person.’
Next, please accept a view that healthcare reform should also participate in the improvement of our nation’s social cohesion. As its most defining character, healthcare reform must become actively connected with the community by community promotion of annually sustained, collaborative investments of social capital among its adjacent communities. For reform, these communities would represent on average 400,000 resident persons. Identifying at least 800 communities that individually pursue a commitment to collaborate with their adjacent communities to improve their social capital prevalence may represent the most important strategy for improving our nation’s social cohesion. The locally initiated, social capital investments in the Survival commons by adjacent communities may represent just too many unknowns. However, if a nationally sanctioned and regionally promoted strategy for improving each community’s Survival commons (aka enhanced safety net) could represent an initial platform for a steadily progressive improvement of our nation’s health as well as its healthcare, then please read on.
The remainder of this Sub-chapter takes about 20-30 minutes to read. It describes a plan to release the paradigm paralysis that currently prevents meaningful healthcare reform. A precise, steadily promoted paradigm reconfiguration will be required to refocus the scientific and humanitarian sophistication of our nation’s healthcare industry. To reconfigure the current paradigm paralysis, the new strategy should begin by slowly building momentum for 3-5 years and then progress more rapidly over 5-10 years. The reconfiguration strategy should refocus our nation’s social-political-economic priorities to reduce the poverty underlying its Population Health as well as its Healthcare. To prepare for the long-term phase, the initial focus will improve the social cohesion and primary healthcare for every community’s resident persons.
a UNIFIED LEXICON for POPULATION HEALTH and its HEALTHCARE
Twenty-three basic concepts, each defined with interconnected terminology, are proposed to inform a goal-directed discussion for establishing a permanently evolving, complex adaptive system with its roots equitably originating in every community. Currently, these twenty-three concepts lack a widely affirmed basis for their precise definition, especially with a pervasive intent to establish their actionable interconnectedness. To apply a modern philosophical concept, a UNIFIED LEXICON for Health may be the most direct means to understand the originating cosmological, biological, and human suffering dimensions that determine the generational attributes of each person’s health. As you will eventually perceive, these 23 concepts are intended to inform the basis for promoting a paradigm shift within healthcare reform. Herein is an initial proposal for defining these twenty-three concepts. They are thematically categorized to represent a comprehensively UNIFIED LEXICON for establishing a new, nationally chartered strategy for the future. So arranged, they are:
- COSMOLOGY – CLUSTER, HUMAN FETUS, PERSON, CARING RELATIONSHIP, and SOCIAL INTERACTION;
- INDIVIDUAL – DISRUPTIVE PROCESS, HUMAN CAPABILITY, CULTURAL SOCIAL-COGNITION, FAMILY, and FAMILY CONVOY;
- NEIGHBORHOOD – WELL-BEING, HEALTH, FAMILY TRADITIONS, and COMMUNITY;
- COMMUNITY – COLLECTIVE ACTION, INSTITUTION, SOCIAL DILEMMA, SOCIAL CAPITAL, and POVERTY;
- NATIONAL – SURVIVAL COMMONS, SOCIAL COHESION, MANAGING THE COMMONS, and COMMON GOOD.
A UNIFIED LEXICON for POPULATION HEALTH and its iconic HEALTHCARE
—————————— C O S M O L O G Y T H E M E ——————————
CLUSTER may be defined as
^
two or more components that establish a sustainable capability
when the components uniquely combine as a result
of their respective attributes representing
synergy among the components,
affinity between the prominent components, and
salutary conditions surrounding these components.
HUMAN FETUS may be defined for HEALTH as
^
the 32-week, final phase of maternal gestation by a fertilized ovum
of the homo sapiens species for finishing the development
of its individually-unique endowment for the eventual character
of an epigenetically-adapted Human Capability that
began during its prior 8-week conception, germinal, and embryonic development;
occurs in tandem with the municipal life of its maternal family and its family convoy; and
achieves sufficient synchrony between its innate temperament and baseline homeostasis
for survival at birth based on the resilience of its maternal gestational stability.
PERSON may be defined for HEALTH as
^
a Human Fetus who
survives its birth to become an ‘additional dependent person’ of their family;
develops an awareness of the nurturing caring relationships originating
from within their family, family convoy, and family traditions as the basis
to acquire their cultural social-cognition skills during early childhood;
refines the discordant social interactions encountered during adolescence
within the municipal life of the community of their family’s home
to form the self-sufficient character of their endowed Human Capability; and
forms joyful, courageous, and hopeful caring relationships with the persons
originating from within their family, its family traditions, and its family convoy
as the basis for their self-sufficient survival as an ‘independent person’ after adolescence.
CARING RELATIONSHIP may be defined as
^
a two-person, social interaction involving diverse scenarios that
begins with mutual respect for each other’s autonomy,
thrives from each person’s steady renewal of their adaptive skills, and
flourishes when the two persons communicate ‘in harmony’ with
warmth, non-critical acceptance, honesty, and empathy.
SOCIAL INTERACTION may be defined as
^
a single encounter, or a variously connected series of encounters,
involving two or more persons who
recognize the intentional occurrence of a situational scenario,
assemble for a purpose, and
participate in the situational scenario based on each person’s understanding
of the situational scenario’s purpose, rules, and likely time course.
—————————— I N D I V I D U A L T H E M E ——————————
DISRUPTIVE PROCESS may be defined for HEALTH as
^
the emergence of cosmologic, biologic, and human suffering disturbances
that co-occur with diverse intensity, time-course phenomena, and
paradoxical patterns to form a cluster with a locally unique configuration
which interacts with the resident persons of a community
to separately alter the self-sufficient resilience
of each resident person’s Human Capability.
HUMAN CAPABILITY may be defined for HEALTH as
^
the generation of consciousness by a person’s Quantum Signaling Brain that
initiates its cognition, innate temperament, and baseline homeostasis before birth;
configures its Cultural Social-Cognition after birth to eventually pursue
“Happiness in an objectively worthwhile life;” * and
acquires certain adaptive skills during the person’s
i. sequentially nested, cognitive development throughout early childhood
when nurtured by the close, caring relationships originating
before birth from within the person’s Family,
their Family Convoy, and their Home’s neighborhood
AND
ii. episodically situational, cognitive development throughout
late childhood, adolescence, and adulthood
to become sustainably self-sufficient after adolescence when
the executive manager of the person’s cognition begins to merge
the bandwidth fluency of their personality and moral reasoning while
the person acquires the spontaneity required to apply social norms for resolving
the discordant, social interactions encountered daily
within the metropolitan life of their Family’s Home, especially when
these discordant social interactions also receive timely mentoring
by the caring relationships originating from within the gatherings
of their Family and its Family Traditions.
CULTURAL SOCIAL-COGNITION may be defined for HEALTH as
^
the cluster of innate
Shared Intentionality, Tribal Social Learning, and Symbolic Learning components
of each person’s cognition that, when developed, promotes
the person’s contribution to the advancement of the Common Good
for the continuing survival of their Homo Sapiens species.
FAMILY may be defined for HEALTH as
^
a cluster of two or more persons that
I. Configures itself with a goal to encourage the broadest expression of each other’s Human Capability and to sustain each other‘s survival by the daily immediacy of their communal, caring relationships;
^
II. Institutes itself intentionally within a community to sustain the cluster’s configuration for one, or more than one, generational cycle of its ‘originating independent person or persons’ when
A. Two ‘originating independent persons’ express a lifelong commitment to their caring relationship as affirmed by a marriage certificate OR
B. One ‘originating independent person’ who is not married, has a sustainable caring relationship with a dependent person, and accepts custodial responsibility for this dependent person as an ‘additional dependent person’;
^
III. Engages their community by offering a salutatory social interaction to every person that each of the cluster’s persons safely encounters during the municipal life of the cluster’s community, irrespective of any ecological or cultural stigmata possibly represented by themself or the other person;
^
IV. Accepts an ‘additional dependent person’ into their cluster, if at least one current ‘originating independent person’ has an established custodial responsibility for the ‘additional dependent person’ as defined
A. Biologically through birth, biological child, or sibling OR
B. Legally through divorce, adoption, guardianship, or foster care;
^
V. Assembles a constellation of Family Traditions to form the shared identity of the cluster’s persons and to guide the responsibilities of the ‘originating independent person or persons’ for their duties to:
A. Establish a household for the cluster within a neighborhood of their municipal or rural community, as their Home, for protecting the resilience of each person’s Human Capability,
B. Identify the ‘independent person members’ who would function as the household’s Family Convoy by nurturing a caring relationship with each household person involving varying degrees of closeness that
1. begins by consolidating any pre-existing Family Convoy members of the cluster’s ‘originating independent person or persons’ or a custodially related ‘dependent person or persons’,
2. evolves overtime for the members to variously participate in the gatherings of the cluster’s evolving Family Traditions to enrich their heritage as the basis for sustaining the cluster’s communal identity, and
3. offers courageous mentorship when requested during a substantial disruptive process affecting the survival resilience of a household person or persons, especially during their adolescence;
C. Promote gatherings of the family members within their Home
1. for a weekly pattern of Family mealtimes to promote a communal responsibility for each other’s biological, emotional, and spiritual nutrition that prevents, mitigates, and ameliorates their daily encounter with discordant social interactions involving modest disruptive processes,
2. for the periodic events involving close persons of their Family Convoy to enhance the ecological and cultural character of the household’s Family Traditions, especially in association with the sentinel transitions occurring throughout the household’s generational cycle, and
3. for the episodic events involving the persons from within their Family Convoy who share mutually supportive attributes for the household’s Family Traditions, especially with those persons residing within the Family’s neighborhood;
D. Define a personal Survival plan for each person of the Family with a goal to
1. arrange for the daily residential needs of each person’s stable Health, especially for Restful SLEEP, Good FOOD, Dedicated EXERCISE and Mentored COURAGE,
2. prevent, mitigate, or ameliorate any person’s encounter with a substantial disruptive process, and
3. adapt the residential capabilities of their Home when required for the personal Survival plan of any household person;
AND
E. Accept an ‘additional independent person’ into their Home, if either the ‘additional independent person’ becomes an ‘originating independent person’ through marriage with a sole ‘originating independent person’ of a Family OR the ‘additional independent person’
1. has the authentic consent of the current ‘originating independent person or persons’ that occurs 01 to 28 days before their first day of residence as an ‘additional independent person’ within their Home and
2. has an authentic personal Survival plan, or next-of-kin approved equivalent, that includes: a. provisions to manage the ‘additional independent person’s Health’ in the event that the ‘additional independent person’ becomes, or is possibly becoming, a ‘dependent person’ who would not qualify as an ‘additional dependent person’ within their Home and b. a notarized Will, power of attorney, and medical power of attorney including its provisions for an advanced directive.
FAMILY CONVOY may be defined as
^
a social network of persons that is associated with each Family,
commonly involving at least 3-5 persons per Family member,
who each maintains a close caring relationship
with at least one Family member involving periodic mentoring that
a. forms initially from among the Family members’ biologically related persons,
especially for continuing a Family’s generationally cultural connections;
b. includes close, nearby residents of the Family’s, Home neighborhood;
c. includes persons who offer an ecological or cultural connection
with the Family Traditions of the Family;
d. evolves periodically by replacing certain persons according
to the Family needs for contact frequency, emotional closeness, or
supportive adaptive skills; and
e. revises the social network’s membership as needed, especially
in association with the occurrence of generational sentinel events.
————————— N E I G H B O R H O O D T H E M E —————————
“WELL-BEING,
when defined as a person’s eudaimonia, represents
‘Happiness In An Objectively Worthwhile Life’. ” (Badhwar 2014)
HEALTH may be defined as
a person’s daily experience of Well-Being that occurs when their survival was or will be:
^
A. Endowed by the gestational formation of sufficient synergy
between the person’s perinatal innate temperament and
baseline homeostasis to achieve sufficient resilience
for the person’s survival after birth;
^
B. Nurtured by the person’s caring relationships that originated
within the person’s Family, its Family Convoy, and
their Home’s neighborhood
i. before birth with a goal to enrich the person’s search
for the broadest portrayal of their Human Capability
during early childhood as a joyful ‘dependent person’ and
ii. after birth with a goal to mentor the person’s personality, moral reasoning,
and “Objectively Worthwhile LIfe” for the broadest portrayal of their Human Capability,
especially during late childhood and adolescent development while becoming
a courageous, sustainably self-sufficient person after adolescence;
^
C. Challenged by the person’s daily encounter with mild disruptive processes
that begins before birth and occurs as interacting combinations and patterns
to cause variably reversible and either beneficent or maleficent effects
on the resilience of the person’s Human Capability,
as prevented, mitigated, and ameliorated lifelong
by the joyful and courageous caring relationships originating
from within the person’s Family, their Family Convoy, and
their Family’s Home neighborhood;
^
D. Matured by the person’s episodic encounters with substantial disruptive processes
that begin before birth and occur as interacting combinations and patterns
to cause variably irreversible and maleficent effects on the resilience
of the person’s Human Capability as variously prevented, mitigated, and ameliorated
lifelong by the person’s family, its Family Traditions, their Family Convoy, and
their Family’s Home neighborhood as well as by their personal Survival plan; AND
^
E. Sustained by the person’s joyful and courageous caring relationships,
their hopeful Family Traditions, and
the Survival commons of their community
until the sustainable resilience of the person’s Human Capability
is no longer sufficient for the person’s survival as a result
of the person’s lifelong encounter with disruptive processes.
FAMILY TRADITIONS have been identified for a healthy Family as (Curran 1983)
^
a cluster of rank-ordered adaptive skills:
“1. communicates and listens, 9. has a balance of interaction among members,
2. affirms and supports one another, 10. has a shared religious core,
3. teaches respect for others, 11. respects the privacy of one another,
4. develops a sense of trust, 12. values service to others,
5. has a sense of play and humor, 13. fosters family mealtime and conversation,
6. exhibits a sense of shared responsibility, 14. shares leisure time, and
7. teaches a sense of right and wrong, 15. admits to and seeks help with problems.”
8. has a strong sense of family in which rituals and traditions abound,
SOCIAL DILEMMA may be defined as
^
a social interaction involving two or more persons,
commonly occurring as a public-goods scenario with a brief-time dimension,
for which one person or a small group of persons chooses to acquire
a short-term benefit for themselves rather than expressing the social norms
that are necessary for all of the persons to receive a long-term benefit.
COMMUNITY may be defined for HEALTH as
^
a cluster of three or more persons, most commonly recognizable
as the persons living within a geographically defined municipality,
who participate in the social networks of this cluster to obtain certain benefits
from their inter-connected spontaneity and thereby acquire a valued awareness
about the communal identity of this cluster’s social networks
that is borne out of the social interactions occurring within each social network and
by each person’s cumulative association of these social interactions
with certain memories of their own ecological and cultural traditions.
—————————— C O M M U N I T Y T H E M E ——————————
COLLECTIVE ACTION may be defined as
a social interaction involving an initial cluster of three or more persons who collaborate with diverse combinations of social capital and ecological and cultural congruence with a goal to improve their status or the status of another cluster by
1. establishing a visioning statement to achieve the initial cluster’s goal, especially when acting in behalf of one, or more than one, social network;
2. preparing an action plan for achieving the initial cluster’s visioning statement, especially when this visioning statement requires a set of tasks for managing a Common Pool Resource; and
3. delegating the action plan responsibilities to one, or more than one, of the following three options: a. the initial cluster itself, b. another cluster of persons, and c. an incorporated private or public institution selected by the initial cluster.
INSTITUTION may be defined as
^
” . . . the prescriptions that humans use to organize all forms of repetitive and
structured interactions including those within families, neighborhoods, markets, firms,
sports leagues, churches, private associations, and governments at all scales.
Individuals interacting within rule-associated situations face choices
regarding the actions and strategies they take, leading to consequences
for themselves and for others. The opportunities and constraints individuals face
in any particular situation, the information they obtain, the benefits they obtain
or are excluded from, and how they reason about the situation are all affected
by the rules or absence of rules that structure the situation. Further, the rules
affecting one situation are themselves crafted by individuals interacting
in deeper level situations. For example, the rules we use when driving to work every day
were themselves crafted by officials acting within the collective-choice rules
used to structure their deliberations and decisions. If the individuals who are crafting
and modifying rules do not understand how particular rules affect actions and outcomes
in a particular ecological and cultural environment, rule changes may produce
unexpected, and at times, disastrous results.” (Ostrom 2005)
SOCIAL CAPITAL may be defined for HEALTH as
^
the predictability of each resident person’s spontaneity for using the social norms
of trust, cooperation, and reciprocity to resolve the social dilemmas
they encounter daily within their community’s municipal life that
become increasingly expressed by the community’s resident persons
when generational, caring relationships progressively populate
the community’s macro-social networks.
POVERTY may be defined as
^
a person’s sustained mental fatigue that reduces their ability to acquire and apply
the daily ecological and cultural, adaptive skills that are necessary to sustain
a household for themself and any additional persons as the basis to arrange for their
restful SLEEP, good FOOD, dedicated EXERCISE, and courageous MENTORING
from which the independent person’s sustained mental fatigue
degrades the expression of their own Human Capability as well as
the Human Capability of any other person or persons residing in the household.
—————————— N A T I O N A L T H E M E ——————————
SURVIVAL COMMONS may be defined for HEALTH as
^
the clusters of community capabilities, viz., enhanced safety net,
that each municipal community assembles to protect their resident persons
from the sudden or sustained occurrence of certain disruptive processes
when these clusters of community capabilities are
^
A. Instituted by each of a nation’s municipal communities to promote
the Stable HEALTH Of Their Resident Persons according
to their nation’s laws and regulations,
at all jurisdictional nested scales, that concurrently apply
to each municipal community’s private and public institutions;
^
B. Enhanced by the daily greetings of kindness and respect occurring
amid the municipal life of their community’s resident persons,
especially when each resident person safely offers
a salutatory social interaction to the other persons they encounter and
each of these persons reciprocates with an appreciative gesture;
^
C. Offered by each municipal community to its resident persons who each may select,
from among its cluster of community capabilities, the benefits and obligations
most suitable for the needs of their own personal Survival plan within
the ecological and cultural traditions of their home’s municipal community;
^
D. Improved by each municipal community’s volunteer, resident persons
who become aware that their community’s clusters of community capabilities
have certain deficits for which a collective action strategy will be necessary
to resolve these deficits with an equitably available, culturally accessible,
justly efficient, and predictably effective action plan;
^
E. Augmented by the collective action strategies that originate
from within each municipal community’s private and public institutions as well as
its social networks to prevent, mitigate, or ameliorate any ‘newly recognizable adversity’
encountered by its resident persons that is related to a locally prominent discontinuity
among their municipal community’s clusters of community capabilities or
their associated Benefits and Obligations,
especially if the ‘newly recognizable adversity’ represents a deficiency
among the Benefits and Obligations currently intended to
prevent childhood maltreatment, improve social mobility,
reduce social isolation, or reduce poverty;
^
F. Protected by each municipal community’s ‘master disaster planning strategy’
that is annually reviewed and revised to prevent, mitigate, and ameliorate
certain locally reoccurring disasters and
the effects of their associated disruptive processes
that variably impair each resident person’s ability
to maintain a personal Survival plan, especially
by the vulnerable resident persons of the community; AND
^
G. Supported by each municipal community’s
public and private institutions, at all jurisdictionally nested scales, and
their nation’s expression of social cohesion when interacting
within the worldwide, marketplace arenas
for its resources, knowledge, and human dignity.
SOCIAL COHESION may be defined for a nation as
^
a general expectation among the resident persons of a nation’s communities
that the resident persons of every municipal community are trustworthy and
that the continuing prevalence of these trustworthy persons improves
when each municipal community continually collaborates
with their adjacent communities to enhance each other’s Survival commons
by their reciprocating investments of social capital.
MANAGING THE COMMONS may be defined as
^
the Design Principles associated with the successful management
of a Common Pool Resource that enable a complex adaptive system of institutions
to offer the equitably available, culturally accessible, justly efficient,
and predictably effective provision of a potentially exhaustible resource for Healthcare
to each community’s resident persons to maintain their Stable Health
based on the shared use of this resource.
COMMENT The presentation given by Professor Elinor Ostrom on the occasion of receiving her Nobel Prize award in 2009 best describes the basis for the Design Principles.
[ http://www.aeaweb.org/articles.php?doi=10.1257/aer.100.3.641 ]
COMMON GOOD may be defined as
^
a worldwide compact formed by the cooperative obligation of every nation
to sustain their social-political-economic, institutional responsibilities for promoting
the broadest expression of human capabilities by each of their resident persons and
to sustain the reciprocating exchange of social capital with their adjacent nations
for ultimately assuring the resilient survival of the worldwide community of persons.
COMMENT The “Universal Declaration for the Common Good of Humanity Project” may represent the most concise, yet comprehensive statement with a purpose to achieve a nation’s COMMON GOOD. Its origin can be traced to a proposal initiated by the 2012 World Forum for Alternatives in Rio de Janeiro and presented to the 2013 World Social Forum in Tunisia. In addition, the “Convention on the Rights of Persons with Disabilities and Optional Protocol” adopted by the United Nations in 2008 might well expand any consideration of the Common Good.
a NEW STRATEGY
Given the heritage of our nation’s healthcare and these twenty definitions, I offer a new view of meaningful healthcare reform. The ultimate character of any new strategy for the reform of our nation’s healthcare will depend on the locally initiated, continuous renewal of each community’s Survival Commons. There are nearly endless priorities that might be identified with this view of healthcare reform. Among these many priorities, I propose that only two priorities are important for true healthcare reform.
First, our nation’s healthcare industry must eventually offer enhanced Primary Healthcare that is equitably available to each resident person within their own community. This health care would strive to offer caring relationships as defined above, thoughts spanning more than 2,500 years. Each community’s collaborative commitment to promote enduring caring relationships between each person and a Primary Healthcare Team should be the essential attribute for this new view of healthcare reform. The ultimate improvement of primary healthcare, community by community, will also require three nationally sanctioned projects. These national projects are necessary to successfully support community-driven healthcare reform.
These national projects are: 1) an evolving comprehensive statement of “best practices” to achieve and sustain the career-long educational preparation of sufficient Primary Physicians for the Basic Healthcare Needs of every community’s resident persons; 2) a set of minimum definitions to use as the basis for the optimal economic reimbursement of enhanced Primary Healthcare; and 3) a HEALTH SECURITY certification process for enhanced Primary Healthcare as the basis for its eligibility to receive optimal economic support.
Second, successful healthcare reform should begin with an assessment of Primary Healthcare, community by community, to assure that it is equitably available to each resident person within their respective community. To support this obligation, each community averaging approximately 400,000 resident persons would support the formation and functions of a Community HEALTH Forum.
COMMUNITY HEALTH FORUM
Approximately 800 of these individual Forums nationwide would each be responsible for their own Community HEALTH Plan as an annual assessment of the equitable availability of its Primary Healthcare and the results of a monitoring process for the efficiency and effectiveness of their community’s healthcare. Eventually, a mature Community HEALTH Plan would have three sections:
- a section devoted to achieving equitably available and HEALTH SECURITY certified Primary Healthcare for each resident person as collaboratively promoted by the relevant community stakeholders; this section would eventually be augmented by a community, data-driven monitoring process for assessing the improvement of the community’s level of Stable HEALTH;
- a Special Projects section to identify the locally prominent adversities affecting their community’s Survival Commons; this section would also include a community-wide assessment of its current social capital asset and the collective action Special Projects currently in place for mitigating the discontinuities that exist within the community’s Survival Commons, especially for social mobility and social isolation; and
- a section to describe their community’s annual review of its Master Disaster Planning Strategy for *) the likely occurrence of predictable disasters as a basis for preventing, mitigating, and ameliorating where possible the effects of these disasters and any unpredictable disasters, *) the applicable preparation in advance of and the recovery efforts immediately following these disasters, *) the community’s connection to their City, County, State, and Federal governments’ disaster preparedness strategies, *) the community’s ongoing collaborative connections with its adjacent counties and the mutual reciprocity of their social capital contributions:
A Community HEALTH Plan offers the best opportunity, annually revised, to highlight certain Special Projects in addition to the usual array of public health needs within each community. The Special Projects might include early childhood education, adolescent development (especially for teenage maternal Well-Being), obesity, mental-health emergency-responsiveness, or homelessness. Disaster preparedness is difficult since the timing and severity of disasters vary considerably. The options available before and after a disaster to mitigate its adverse effects are the most important attribute of these plans. Furthermore, the preparedness for predictable disasters then establishes the basis for managing the community’s unpredictable events.
After a few years, the national character of these 800 Community HEALTH Plans is likely to reflect the diversity of local attributes and needs but could eventually coalesce on the importance of certain details. Finally, the benefits of disaster planning are less obvious for predicted disasters than it is for unforeseen disasters. The resilience of each community’s social capital commitment to advance its Survival Commons would be the most profound underlying component for the success of its disaster preparation. This attribute would be enhanced by each community’s collaboration with its adjacent communities.
Each Community HEALTH Forum would be formed to include participation by the locally applicable, community-benefit stakeholders. As ADVOCATES within the overall umbrella of NATIONAL HEALTH, each Forum would participate along with the other nearly 800 Community HEALTH Forums to incorporate the collaborative options that their community’s healthcare institutions have already identified. An underlying theme for each Forum would be its obligation to promote trust, cooperation, and reciprocity among its existing community institutions. Beginning more than 400 years ago, the enduring tradition of locally mobilized volunteerism may be the most important heritage for sustaining our nation’s worldwide autonomy and as well as for the continuous improvement of our nation’s HEALTH.
THREE “Mision To The Moon” GOALs
Unintentionally, the traditions of our nation’s healthcare industry have interacted since 1969 to paralyze its capacity to initiate and perpetuate its own reform. To reverse this paralysis, a supreme national commitment will be required to implement a thoroughly reconsidered basis for healthcare reform. The commitment required for this level of reform should represent our nation’s next, “mission to the moon.” After starting this newly reconsidered “moon-shot,” I propose three very specific GOALs for healthcare reform:
- Reduce annual health spending by the equivalent of a steady reduction from 18.0% in 2019 to 13.0% of our nation’s economy (GDP) within 10 years;
- Reduce the annual incidence of women dying from a pregnancy (in 2019) from 20.1 to 6.0 deaths per 100,000 live births, (maternity mortality ratio) within 10 years; and
- the ratification by all States of a Charter established by Congress for a new nationally constituted, semi-autonomous institution to guide this reform within 10 years.
These GOALs beginning in 2022 and ending in 2032 would: 1) reduce annual health spending as a portion of our nation’s GDP by 28%, 2) reduce the number of women dying from a pregnancy by 70%, and 3) achieve legislative by all 50 States for their State’s a full collaboration with NATIONAL HEALTH. NATIONAL HEALTH would be Federally funded with fixed, cost of living adjusted, annual budget of $1.50 per citizen and have ultimate responsibility for achieving these three GOALS.
Reducing the health spending for our nation’s healthcare will be especially important for our nation to maintain its autonomy within the marketplace arenas for the world’s Resources as well as for its Knowledge and Human Dignity. Continuing our nation’s current deficit spending will eventually achieve a debt per citizen that is the same as it was for Greece in 2011. As of 2019 after 5 years of austerity, their nation was finally able to arrange IMF loans to support their long-term debt without international supervision.
During 2019, total health spending for our nation’s healthcare was $3.92 Trillion. It represented 18.0% of our national economy. Almost all of the other developed nations had spent less than 13% of their nation’s economy on healthcare. Using a benchmark of 13.0% as a goal, the excess health spending in 2019 could be estimated as the difference between 13.0% and 18.0% of our nation’s economy in 2018. This excess health spending for our nation’s healthcare in 2019 would have been $1.008 trillion or the equivalent of fighting 10 Iraqi/Afghanistan wars in 2005, simultaneously! To finish this analysis, the Federal government paid cash for 45% of our nation’s healthcare in 2019, representing $454 Billion of its excess cost. Most importantly, this $452 billion represented 46% of our Federal deficit of $984 Billion in 2019.
GETTING STARTED
The excess cost of our nation’s healthcare represented the largest contribution to the 2019 fiscal deficit of our nation’s Federal government. Furthermore, there is no evidence that the current overall strategy for healthcare reform would substantially improve the overall efficiency and gaps of effectiveness by our nation’s healthcare. Beginning today, “lift-off” for NATIONAL HEALTH could be 6 months away. Our nation’s autonomy within the worldwide community is at stake. Established by a Congressional Charter for the benefit of our nation’s future, each resident person would eventually recognize the V I S I O N of the new institution by its name. I propose the following visioning statement for NATIONAL HEALTH:
V I S I O N – Stable HEALTH For Each Resident Person
^
MISSION – To plan healthcare reform
with a continuously renewed understanding of our nation’s
Resources, Knowledge, and Human Dignity
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PRINCIPLES – Altruism . Trust . Cooperation . Reciprocity . Excellence
To understand the basic dimensions underlying the future of healthcare reform, I offer a brief history lesson. The history lesson begins with the following question. What is the heritage of our nation that has evolved from the passions of the immigrants who came here from foreign lands? To be sure, many passions motivated the men and women who have historically emigrated and continue to emigrate from their homeland to North America. Among these motivations, three passions probably represent the essential heritage underlying their emigration.
One passion has been a desire to leave their homeland’s authoritarian, autocratic, centralized, and coercive government. A second passion has been a desire to become a citizen of a nation with constitutionally defined and enforced freedom of speech. To be comprehensive, our First Amendment rights also include freedom of religion, print, assembly, and petition.
Since 2001, the world’s continuing and rapidly evolving events represented the beginning of a new era for the worldwide community. This new era clearly represents an evolving threat to each person’s Human Dignity when living in a nation with an autocratic, authoritarian, centralized, and coercive government. According to the NEWSEUM in 2014, only 9% of the world-wide population, who lived outside of the USA, were citizens of a nation with our enforced, First Amendment rights.
The third passion that motivated immigrants was, and still is, the chance to start a new way of life. Starting in 1600, a new way of life was especially prominent for the early immigrants who came to North America and endured life-threatening hardships. Most early immigrants accepted, in advance, the profound and unknown dangers of these hardships. It was a small price to pay for the chance to achieve a substantially and permanently better quality of life. Relocating to North America and leaving “taxation without representation” was, and continues to be, worth these life-threatening risks.
Unfortunately, some immigrants have come to our nation for other reasons. Human trafficking, “slavery,” has forced and continues to force many immigrants to emigrate for the profit motives of their captors. In 1865, the 13th Amendment to our nation’s Constitution prohibited overt slavery. The forced loss of human dignity for the African emigrants was and continues to be a devastating failure of our nation’s commitment to uniformly honor the human dignity of every immigrant person. The lingering, generational impact for these immigrants continues to haunt the sincerity of our nation’s First Amendment obligations.
Other immigrants have come to our nation only to serve their own predominantly self-centered economic or social values. Finally, our early immigrants forced the Native North Americans to emigrate and, as a result, become immigrants on their own land. Our nation’s legal tradition of assumed property rights drove the forced immigration of our Native Americans. In 1879, Native Americans achieved protection under the law from an Omaha Federal Court decision by Judge Elmer Dundy for Chief Standing Bear of the Ponca Tribe. To achieve this decision, two attorneys had prevailed with a writ of “habeas corpus ad subjiciendum.” The two attorneys were employees of the Union Pacific railroad in Omaha and members of a local Congregational Church who actively affirmed their pro bono commitment.
HUMANITARIAN VERSUS SCIENTIFIC MANDATE
Despite the reasons for immigration, successful survival in North America ultimately required self-discipline, hard work, and altruism – a desire to help others. For nearly 500 years, this dedication to individual survival has been associated with an expectation that each community would function better if its resident persons survived primarily on their own with the assistance of their Extended Family despite life’s tragic events. For the 12 million immigrants who arrived in New York City at Ellis Island, any healthcare that was eventually available to them was a privilege based on the economic success of their own survival. The immigrants who passed through Ellis Island represented the ancestors of nearly 40% of our nation’s current citizens when it closed in 1954. They included my grandparents from Sweden.
Between 1850 and 1900, the knowledge for anesthesia and infection control began to evolve. This meant that the benefits of surgery eventually required a specific location outside of a person’s home. Prior to this combination of newly evolving technology, health care almost always occurred within a person’s home as offered by members of the person’s Extended Family and micro-Social Networks. Except for war-time or travel away from home, the only persons who did not receive this level of healthcare were the persons without a Family, now recognized as homeless.
Almost every community beginning around 1700 began to have rudimentary hospitals for the homeless, currently most commonly identifiable as “nursing homes.” Most of these were community- established by county and city levels of government or religious institutions. With the evolution of surgery, some of these early nursing homes eventually adapted to become modern-day hospitals. Most importantly, the early and eventually profound evolution of life-preserving healthcare beyond the confines of a person’s home removed a powerful means to maintain their Family Traditions. Specifically, these Family Traditions were important to sustain the mutually shared commitments within a Family and its Extended Family to care for each other. Originating slowly following the Civil war ending in 1865, newly constructed hospitals eventually became more common after World War I and especially after World War II.
Along with the shift of healthcare to a location ‘foreign’ to most resident persons, the cultural and ecologic origins of each person’s HEALTH also became exposed to an increasingly complex society. The newly evolving changes involved family-relocation frequency, electronic communication, urbanization, and women’s professionalization within the workforce. A continuing cycle of violence, worldwide and neighborhood by neighborhood, has evolved since the end of WWII in 1945 and especially after 2001. Amid the adaptation to these changes, we have arrived at a time whereby a person’s Extended Family and their Family Traditions no longer offer the traditional emotional resources for mentoring each person during episodes of Unstable HEALTH, especially for women while adapting to a pregnancy.
All of this has led to a diminished commitment within each community to sustain the Stable HEALTH of its resident persons by their community’s Survival Commons, aka safety net. Beginning in 1969, the disruptive processes that represent the causes of Unstable HEALTH have become increasingly beyond the control of our healthcare industry. Given the vast social and economic changes of the last 150+ years since the Civil War, we have arrived at a level of ecological and cultural turmoil within our world and our nation that is unprecedented by any definition.
PARADIGM SHIFT with PARALYSIS
Beginning in 1969, a rapidly evolving improvement began to occur in the sophistication of healthcare that is now available for Complex Healthcare Needs. Unfortunately, the improved quality of health care for Complex Healthcare Needs has not been matched by a similar improvement in the health care for the Basic Healthcare Needs of each resident person. This change since 1969 means that self-discipline, hard work, and altruism no longer guarantee that health care is equitably available for the Basic Healthcare Needs of each resident person, even for the persons who have achieved economic success. Inequitably available health care for Basic Healthcare Needs can be especially profound *) for any woman before, during, and following a pregnancy and *) for any resident person who is an infant, disabled, or homeless.
By 2009, the poorly recognized imbalance that had evolved between the health care for Basic Healthcare Needs and for Complex Healthcare Needs represents a root cause for the problems within our nation’s health care. Furthermore, the health care for Basic Healthcare Needs has deteriorated without a strategy to assure that Primary Healthcare is equitably available to and ethnographically accessible by each resident person within their own community. The effect of this deficiency has led to severe problems within our healthcare industry, as in its cost and preventable maternal deaths.
The imbalance is partially the result of an inadequate level of financial capital for the Basic Healthcare Needs of each resident person as compared to the financial capital that is available for their Complex Healthcare Needs. It is not the fault of specific resident persons or an organized group of resident persons. It began to occur, more prominently, after Congress authorized Medicare and Medicaid in 1965. Between 1960 and 2019, the portion of our nation’s economy allocated to healthcare has more than tripled.
Unfortunately, the flow of these resources preferentially into the health care for Complex Healthcare Needs has produced a deeply entrenched and pervasive co-dependency between the institutions paying for Complex Healthcare Needs and the institutions offering healthcare for these Complex Healthcare Needs. These institutions are the medical-school affiliated hospitals and private health insurance companies. The institutional co-dependency is a contributory root cause of the Paradigm Paralysis afflicting our nation’s healthcare industry.
The Paradigm Paralysis means that the heritage of our nation has produced a healthcare industry that is unable to start or sustain its own reform. Since 1969, this industry has required a new and widely supported institution to guide its reform. Our nation’s agriculture industry has had its Cooperative Extension Service since 1914, and our nation’s monetary policy has had its Federal Reserve since 1913. As a result, our nation’s agriculture industry is the most justly efficient and reliably effective among the world’s nations, by a wide margin, and our nation’s dollar is still the most prominent basis for asset transfer among nations in spite of our nation’s increasing indebtedness. Now, 100+ years later, a similar institution for our nation’s healthcare industry must begin by promoting Primary Healthcare, community by community, that is equitably available to each resident person within their own community.
In addition, our nation must begin a tradition to establish its ability to re-energize a local ‘collaborative’ heritage within each community. This heritage would sustain a nationwide tradition that recognizes each community’s obligation to promote Stable HEALTH for each of its own resident persons. The new strategy should also focus on the HEALTH of its resident persons with special needs, especially every infant or toddler and their mother. Thirty years from now, our nation’s autonomy within the worldwide community will depend on the sustainability of each community’s Survival commons to foster the caring and learning generations of our nation’s future resident persons. A newly enriched definition of HEALTH helps to explain this assertion. It is one of the 18 interconnected definitions listed above.
“GOVERNING THE COMMONS” (Ostrom 1990)
Because of its profound inefficiency, our healthcare industry is no longer affordable within our nation’s economy. A “Tragedy of the Commons” has occurred. The traditions of our national heritage have led to this crisis. Exploring the basis for remodeling these traditions is a central theme for NATIONAL HEALTH. The TRADITIONS Chapter and its Sub-Chapters explore this theme in greater detail. They attempt to explain why the problems are so difficult to define and so resistant to implementing solutions that originate from within our nation’s healthcare industry. Simultaneously, an overall strategy has not originated from within the mainstream of our nation’s private and governmental institutions, at all scales.
Professor Elinor Ostrom points the way with her studies described in nine books published between 1990 and 2010. “Governing the Commons” is the first book in the series. Within this series, she describes an analysis of shared use strategies applied with an intent to preserve a natural resource, such as the freshwater aquifer under the city of Los Angeles, California. Eventually her studies, along with the research of numerous colleagues, have defined the Design Principles that characterize the successful governance by any institution with a responsibility to preserve a common-pool resource. For healthcare, the common-pool resource may be defined as the portion of our national economy devoted to health spending.
NEW CONCEPTS
For lasting healthcare reform, any new strategy should include a continuing search for new concepts that would be uniquely applicable to the future reform of our nation’s healthcare industry. The search for these concepts should not necessarily represent an intent to start a new tradition or to match the institutional heritage of another nation. Among the world’s developed nations, the traditions of our own healthcare industry are unique. Given our own traditions, this proposal for NATIONAL HEALTH or any other reform proposal should refine these traditions rather than replace them. The other developed nations of the world have adopted a variety of models for their own healthcare. They are instructive but do not easily provide a specific model to duplicate for our nation.
The search for concepts that are possibly applicable to healthcare reform by NATIONAL HEALTH has focused primarily on the last 100 years. Within the public arena, I have selected a set of concepts for healthcare reform based on how they would jointly interact for a larger impact. These concepts represent the realms of knowledge from a diverse group of scholars. I propose that taken together they represent a pragmatic basis for the comprehensive reform of our nation’s healthcare. It is described by the NATIONAL HEALTH Chapter and its Sub-Chapters.
HEALTH CARE versus HEALTHCARE — A NEW ERA
Given our nation’s pioneer heritage, the historic traditions of our nation’s healthcare industry have evolved, especially since 1969, into a diverse mix of institutions. This industry has become increasingly unstable since 2011. In 2011, an unexpected number of critical medications were suddenly no longer available. One year later, a failure to maintain quality control standards by a compounding pharmacy in Massachusetts led to more than 75 deaths throughout our nation. This state’s Public Health Department had failed to monitor the quality control standards maintained by the compounding pharmacy. The regulatory failure ultimately contributed to the disaster. Similar disasters involving compounding pharmacies in Tennessee and Texas began to unfold at mid-year in 2013.
In spite of a rapidly worsening incidence of accidental and intentional opioid-overdose related deaths in 2018, our nation’s healthcare industry endured a shortage of an intravenous form of narcotics at mid-year. An underlying observation further mystified the simultaneous occurrence of the death rate and monitoring deficiencies of hospital inventory supplies. The opioid-related mortality incidence was much higher in the States who had implemented a Medicaid expansion policy through Obamacare as opposed to the States that had NOT implemented Medicaid expansion in 2017.
Next, the opening phase of the National Health Insurance Exchange in October of 2013 was disheartening, at best. And finally, in 2014, the problems with the Veterans Administration represented a recurring theme of institutional leadership problems. This subsequently reached a new peak when it was announced in 2017 that several of their hospitals had lost inventory control of their narcotic medication supplies.
Any reform strategy to promote a broad improvement throughout the diverse institutions of a nation’s large industry must proceed with caution. Improving the daily HEALTH of individual resident persons must be balanced by the evolving continuum of healthcare over time and how it fits together for the seamless health care needs of every resident person. Hopefully, the unstable series of events, noted above over 7 years, was only an isolated occurrence. The evolving reality of the ACA 2010 could worsen this turmoil given its inability to fundamentally unravel the Paradigm Paralysis strangling our nation’s healthcare.
To formulate a new strategy for a carefully defined and implemented healthcare reform strategy, the TRADITIONS Chapter and its Sub-Chapters analyze the essential traditions of our nation’s healthcare. Five of the Sub-Pages propose a solution for specific root causes of the Paradigm Paralysis afflicting our nation’s healthcare. Based on this analysis, the NATIONAL HEALTH Chapter and its Sub-Chapters describe a new institution to be Chartered by Congress. See the OVERVIEW Chapter for further implementation details.
If you appreciate the fundamental value of concepts and ideas as a basis for shaping the future course of events, then you also have a unique perspective for considering the character of our nation’s healthcare. Overall, NATIONAL HEALTH integrates concepts originating from the traditions of thought underlying the social contract for the governance of Western nations. They are sociology, economics, physics, psychology, biology, anthropology as well as medicine.
Let me introduce you to Eric Hoffer, Leon Festinger, Carl Rogers, Thomas Kuhn, Lawrence Weed, Garrett Hardin, Peter Drucker, Steven Covey, and Elinor Ostrom. As a basis for healthcare reform, the cohesion of their concepts as well as the concerns of many persons expressed to me during their personal healthcare represents the essential momentum guiding the conceptual priorities for this healthcare reform proposal.
REPRISE & RECAPITULATE — “The Future As History”
The brief quotation cited above represents the title of a book written by Robert L. Heilbroner. It was printed in 1960. He reviewed the essential trends within our nation before 1960 as a basis to describe a view of our nation’s near-term, future evolution. He was substantially correct. The knowledge for assessing future options was known then, as it probably is knowable now, for the immediate future of our nation’s healthcare reform. To view our nation’s heritage during the last 400 years, isolated episodes of supreme commitment and purpose have defined our nation’s history. Remember, especially, the voyage of the Mayflower in 1620, the Declaration of Independence in 1776, the 13th Amendment to the Constitution in 1865, women’s suffrage with the 19th Amendment in 1920, our national commitment to WWII after the Pearl Harbor attack in 1941, our nation’s Mission to the Moon after Sputnik in 1957, and our nation’s sudden awakening to global terrorism after the World Trade Center attack in 2001.
I propose that the knowledge and locally expressed needs for social cohesion are already definable as the basis for the reform of our nation’s healthcare. With a “Moon Shot” level of precision and resolve, fundamental healthcare reform could reduce the cost of our nation’s healthcare from 18.0% of the national economy in 2019 to 13.0%. Remember again that it was 5.0% in 1960. This same strategy could reduce our nation’s number of women who died in 2016 from a pregnancy, from 24.6 to 7.0 deaths per 100,000 living births. The improvement in maternal HEALTH would have prevented at least 700 maternal deaths during 2016, assuming 4 million live births. The analysis is overall unchanged with 2019 data.
It is highly unlikely that our nation’s current strategy for healthcare reform could achieve these results within the next 10 years, or even come close. Indeed, we must begin by first acknowledging the pervasive paradigm paralysis afflicting our nation’s healthcare. Importantly, this paradigm paralysis increasingly compromises our nation’s autonomy within the worldwide marketplaces for its Resources and Human Dignity. Now is the time for a new strategy to promote social cohesion within each community’s Survival Commons, as the ultimate basis for improving the HEALTH of each resident person within every community. There are validated Design Principles that apply to the use of collective action strategies for managing a common-pool resource, as in the portion of our nation’s economy devoted to healthcare.
Since 1960, our nation’s health spending has increased from 5.0% of the GDP to 18.0% in 2019. It represents an increase of 5.0% annually, adjusted for inflation and economic growth, most sensibly explained by Parkinson’s Law. Using the Design Principles defined by Professor Elinor Ostrom and validated by many colleagues, NATIONAL HEALTH would build the widely supported authority necessary to implement the strategies required at the national, state, and local levels for healthcare reform. Its budget should be defined as a Federal expense that is fixed at $1.50 per citizen annually.
Our currently evolving progress for healthcare reform continues to focus primarily on universal health insurance. The Affordable Care Act of 2010 was a magnificent accomplishment, in spite of its deficiencies. Unfortunately, it is actually worsening the level of efficiency within our nation’s healthcare industry. And, it does very little to sponsor the fundamental reforms necessary to achieve equitably available, enhanced Primary Healthcare for each resident person, community by community.
To begin true healthcare reform, it should be locally implemented, regionally coordinated, and nationally promoted. As cited above, former Senator Barber reminds us that “The language of citizenship suggests that self-interests are always embedded in communities of action and that, in serving neighbors, one serves one-self. NATIONAL HEALTH represents a means to achieve a V I S I O N for healthcare reform through communities of action.
Stable HEALTH For Each Resident Person