community-centric
R A T I O N A L E
For improving our nation’s “population health”
and its healthcare, ALTOGETHER
INTRODUCTION
7.5
“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 one-self.”
Benjamin R. Barber (1939 – )
Before getting started, please take a moment to read again the quotations cited above. As represented by these authors, their views of a person’s life are similar to my own. Do you also share their views 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 will not improve the health care offered for the Basic Healthcare Needs of every resident person. This Primary Healthcare is often hard to locate or difficult to use because of its inequitable payment systems, the travel time to arrive at its location, or the need to pass through adverse ethnographic “steps and doors” to connect with its source.
For truly lasting healthcare reform, any new nationally sanctioned strategy must promote enhanced Primary Healthcare that is “equitably available” to each resident person within the Survival Commons (aka augmented safety net) of their own community. Every other developed nation of the world has a nationally sanctioned strategy to assure the equitable availability of enhanced Primary Healthcare for each of their resident persons, community by community.
The absence of this priority contributes substantially to the failure of our current healthcare reform to achieve broad improvement in the overall cost and quality of our nation’s 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 would offer enduring caring relationships as the basis for promoting “Stable HEALTH For Each Resident Person.”
Next, please accept the concept that healthcare reform should also participate in the improvement of our nation’s social cohesion. As its most defining character, healthcare reform must collaborate with the promotion of locally sponsored investments of social capital within every community, each community representing on average 400,000 resident persons. Eight hundred communities with a commitment to collaborate with their adjacent communities for improving each other’s social capital investments in their respective Survival Commons may represent just too many unknowns. However, if a nationally promoted strategy to promote every community’s Survival Commons (aka augmented safety net) with reciprocal contributions to each community’s social capital could a plausible platform for our nation’s healthcare reform, 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 reform of our nation’s population health as well as its healthcare. A precise paradigm realignment will be required to refocus the scientific and humanitarian sophistication of our nation’s healthcare industry. To reconfigure the current paradigm paralysis, a new strategy should begin by slowly building momentum for 3-5 years. And then, more rapidly over 5-10 years, it should reconcile the humanitarian and scientific mandates for our nation’s healthcare with an initial focus on the social cohesion and Basic Healthcare Needs of every community’s resident persons.
a UNIFIED EPISTEMOLOGY for HEALTH
Fifteen basic concepts, each defined with interconnected terms, could newly inform the basis for any goal-directed discussion about a permanent strategy to impove our nation’s ‘population health’ and its ‘healthcare’. Currently, each of these concepts has not achieved a widely affirmed basis for their precise definition, especially for an intent to establish their interconnectedness. To apply a modern philosophical concept, a Design Epistemology for HEALTH will be necessary to understand the originating cosmologic, biologic, and human suffering dimensions that determine the generational expression of each person’s HEALTH. As you will eventually perceive, these concepts would promote a new nationally instituted and locally implemented strategy, community by community, for the reform of our nation’s ‘population health’ and its iconic ‘healthcare.’ Alphabetically listed, here is an initial proposal for fifteen concepts to represent a unified Design Epistemology for HEALTH:
- CARING RELATIONSHIP,
- CLUSTER,
- COLLECTIVE ACTION,
- COMMUNITY,
- DISRUPTIVE PROCESS,
- FAMILY,
- HEALTH,
- PERSON,
- SALUTARY CONDITIONS,
- SOCIAL CAPITAL,
- SOCIAL COHESION,
- SOCIAL DILEMMA,
- SOCIAL INTERACTION,
- SURVIVAL COMMONS, and
- WELL-BEING.
A DESIGN EPISTEMOLOGY for POPULATION HEALTH and its HEALTHCARE
CARING RELATIONSHIP may be defined as
^
a social interaction involving two persons that
begins with beneficence and deference for each other’s autonomy,
thrives by each person’s steady renewal of their adaptive skills, and
flourishes when the two persons communicate ‘in harmony’
with warmth, non-critical acceptance, congruence, and empathy.
CLUSTER may be defined as
^
two or more components that
become recognizable as a sustainable capability
when they are combined from the individually unique attributes of
synergy among the respective components,
affinity between the prominent components, and
salutary conditions surrounding the components.
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 congruent ethnography with a goal to improve their status or the status of an alternate cluster by
1. establishing a Visioning Statement for the cluster’s Action Plan, especially when acting in behalf of a community;
2. preparing an Action Plan for achieving the cluster’s Visioning Statement including, if applicable, the special provisions for managing a common-pool resource; and
3. delegating the specific responsibilities for implementing the Action Plan to one, or more than one, of the following three options: a. the initial cluster itself, b. the alternate cluster of persons, and c. an incorporated private or public institution selected by the initial cluster.
COMMUNITY may be defined as
^
a cluster of three or more persons, most recognizable
as the persons residing within a geographically defined municipality,
who share certain uniformly identifiable attributes and
a valued awareness about their interconnected identity that is
borne out of the cluster’s continuing social interactions and
each person’s association of these social interactions with certain memories
of their own cultural and ethnic traditions.
DISRUPTIVE PROCESS may be defined for HEALTH as
^
the emergence of cosmologic, biologic, and human suffering aberrations,
that occur separately with diverse dimensions and time-course phenomena and
selectively converge to form a uniquely occurring cluster
of inter-related disturbances which interact with a community’s resident persons
to variously alter each resident person’s resilience for their continuing survival.
FAMILY may be defined for HEALTH as
^
a social interaction involving a cluster of two or more persons that
^
I. CONFIGURES itself with a goal to enrich each other’s survival by the spontaneous immediacy of their caring relationships;
^
II. INSTITUTES itself within a civic community to sustain the cluster’s configuration for a 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 safely offering a greeting social interaction to every person that each of the cluster’s persons encounter daily during the civic life of the cluster’s community, irrespective of any social stigmata possibly represented by either themselves or another person; AND
^
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 adoption, guardianship, foster care, or divorce.
^
V. ASSEMBLES a constellation of Family Traditions to maintain the cluster’s shared identity and to guide the responsibilities of the ‘originating independent person or persons’ for their duties to:
A. Establish a communal household within a neighborhood of their community, their Home, for enriching each person’s resilience with joyful courage;
B. Select a convoy of mentoring persons who each maintain a caring relationship with at least one of the cluster’s persons that
1. begins by coalescing the pre-existing convoys of the cluster’s ‘originating independent person or persons’,
2. evolves over time during the cluster’s sentinel transitions, especially in association with Unstable HEALTH, and
3. offers Courageous Mentorship when requested during a sentinel disruptive process that affects the Well-Being of one or more of the cluster’s persons;
C. Promote gatherings of the cluster’s persons within their Home
1. for a weekly pattern of Family Mealtimes to share with each other the physical, emotional, and spiritual nutrition that ameliorates each person’s daily encounters with social dilemmas involving modest disruptive processes,
2. for a periodic gathering with the persons of their Extended Family to enhance the ethnographic character of the cluster’s Family Traditions, especially in association with the sentinel transitions occurring throughout the cluster’s generational cycle, and
3. for an episodic gathering with the persons from within their micro-social networks who share mutually supportive attributes of the cluster’s Family Traditions, especially those persons residing within the cluster’s immediate neighborhood;
D. Define a Personal Survival Plan for each person of the cluster and, when appropriate,
1. prevent, mitigate, or ameliorate each person’s encounter with substantial disruptive processes,
2. adapt the residential capabilities of their Home, and
3. arrange for the lifelong needs of each person’s Stable HEALTH, especially for their Restful SLEEP, Good FOOD, Dedicated EXERCISE, and Mentored COURAGE; 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 cluster OR the ‘additional independent person’
1. has the consent, preferably written and notarized, of the current ‘originating independent person or persons’ that occurs 01 to 28 days before the first day of the ‘additional independent person’s’ initial residence within their Home and
2. has a written Personal Survival Plan or its next-of-kin approved equivalent that preferably 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.
HEALTH may be defined as
^
a person’s daily experience of Well-Being during their lifelong survival that is
^
A. Endowed by the gestational formation of sufficient synergy
between the person’s innate temperament and underlying baseline homeostasis
for sustainably modulating the person’s adaptive resilience
immediately after birth and subsequently during early childhood;
^
B. Nurtured by the person’s caring relationships that originate from within
the person’s Family and Extended Family who encourage the person’s search
for the broadest portrayal of their sentient reflective-Cognition
Cluster of Human Capabilities as a joyful dependent person and from within
the micro-social networks and Convoy of the person’s Family who episodically mentor
the adaptive resilience of the person’s innate temperament during the social interactions
occurring while becoming a courageous independent person;
^
C. Challenged by the person’s daily encounters with modest disruptive processes
beginning before birth and occurring as interacting combinations and patterns
to cause variably reversible and either beneficent or maleficent effects
on the adaptive resilience of the person’s combined innate temperament and
sentient reflective-Cognition Cluster of Human Capabilities as ameliorated lifelong
by the joyful caring relationships originating from within
the person’s Family, its Extended Family, and its micro-social networks;
^
D. Matured by the person’s episodic encounters with substantial disruptive processes
beginning before birth and occurring as interacting combinations and patterns
to cause variously irreversible and maleficent effects on the resilience
of the person’s combined Clusters of Human Capabilities and innate temperament
as variably prevented, mitigated, and ameliorated lifelong
by the Personal Survival Plan of the person; AND
^
E. Sustained by the person’s hopeful caring relationships,
the joyful and courageous Family Traditions of the person’s Family, and
the Survival Commons of the person’s community
until the resilience of the person’s combined
Clusters of Human Capabilities and innate temperament
is no longer sufficient for the person’s survival
from their lifelong encounters with disruptive processes.
PERSON may be defined as
^
a fertilized ovum of the species Homo Sapiens
with its own individually-unique Clusters of Human Capabilities that
survives embryonic transformation during maternal gestation
to form its own unique innate temperament and
sufficient resilience for survival at birth.
SALUTARY CONDITIONS FOR THE SUSTAINABLE MANAGEMENT
OF NATIONAL HEALTH SPENDING AS A COMMON POOL RESOURCE
may be defined as: (Wilson DS, Ostrom E & Cox ME 2013)
^
I. CLEARLY DEFINED BOUNDARIES;
II. PROPORTIONAL EQUIVALENCE BETWEEN BENEFITS AND COSTS;
III. COLLECTIVE-CHOICE ARRANGEMENTS;
IV. MONITORING;
V. GRADUATED SANCTIONS;
VI. CONFLICT RESOLUTION MECHANISMS;
VII. MINIMAL RECOGNITION OF RIGHTS TO ORGANIZE; and
VIII. DECENTRALIZED GOVERNANCE WITH APPROPRIATE SUBSIDIARITY, ESPECIALLY FOR RISK MANAGEMENT. (NOTE: The last Condition has been edited for this DESIGN EPISTEMOLOGY from the original citation.)
SOCIAL CAPITAL may be defined for as
^
the bystander spontaneity to use the norms of trust, cooperation, and reciprocity
for resolving the social dilemmas encountered within a community
that becomes more uniformly expressed by the community’s resident persons
when generational caring relationships
increasingly permeate the community’s social networks.
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 each other’s community are trustworthy and
that the prevalence of these trustworthy persons improves
when every community persistently collaborates with their adjacent communities
to support each other’s Survival Commons with mutual contributions of social capital.
SOCIAL DILEMMA may be defined as
^
a social interaction involving two or more persons,
commonly occuring as a public-goods scenario with a brief time-interval,
for which one person or a small group of persons may choose to acquire
a short-term benefit for themselves rather than choosing to join
the other person or persons participating in the encounter even though
that is required for all of the persons to receive a long-term benefit.
SOCIAL INTERACTION may be defined as
^
a social relation involving a single encounter or series of encounters
by either two persons or more than two persons
who assemble for a purpose,
accept their underlying ethnographic diversity,
recognize the occurrence of a situational scenario, and
participate based on each person’s understanding
of the scenario’s purpose, rules, and likely time-course.
SURVIVAL COMMONS may be defined as
^
the Clusters of Community Capabilities
that each community sustains 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 a nations’ communities to “…promote the general Welfare…”
of its resident persons according to the nation’s laws and regulations at all scales
that concurrently apply to each community’s private and public institutions;
^
B. Enhanced by the expressions of kindness and respect
among the community’s resident persons during its civic life,
especially when one person safely offers a greeting social interaction
to another person who responds with an appreciative gesture;
^
C. Offered by the community to each of its resident persons who may select,
from among its Clusters of Community Capabilities, the specific Benefits and
Obligations most suitable for the needs of their own Personal Survival Plan
within the ethnographic traditions of the community;
^
D. Improved by the community’s volunteer, resident persons who become aware
that their community’s Clusters of Community Capabilities may have certain deficits
for which a collective action strategy may be required to improve their over-all
equitable availability, ethnographic accessibility, just efficiency, and reliable effectiveness;
^
E. Augmented by the collective action strategies that originate
from within the community’s institutions and social networks
to prevent, mitigate, or ameliorate any “newly recognizable adversity” encountered
by its resident persons and related to a locally prominent discontinuity
among their community’s Clusters of Community Capabilities or their associated
Benefits and Obligations, especially if the “newly recognizable adversity” reflects
either a deficiency of equitably available, Primary Healthcare or
a deficiency among the Benefits and Obligations currently promoting
improved social mobility and reduced social isolation;
^
F. Protected by the community’s Master Disaster Planning Strategy
that is annually revised to prevent, mitigate, and ameliorate
the effects of certain locally-predictable disasters,
especially when their disruptive processes would cause impairment
of the capability to maintain a Personal Survival Plan
by a vulnerable portion of the community’s resident persons; AND
^
G. Supported by the community’s
public and private institutions at all scales and
their nation’s level of autonomy
within the worldwide, marketplace arenas
for its Resources, Knowledge, and Human Dignity.
“WELL-BEING, when defined
as a person’s highest prudential good, represents
^
‘ Happiness In An Objectively Worthwhile Life ‘. ”
Neera K. Bradhwar (1947- )
a NEW STRATEGY
Given the heritage of our nation’s healthcare and these thirteen 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 the 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 2016) from 24.6 to 7.0 deaths per 100,000 live births, i.e., its maternity mortality ratio within 10 years; and
- the eventual 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 for an annually fixed budget of $1.50 per citizen and have full responsibility to achieve the 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 spend 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
^
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 in spite of 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 own 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 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 for 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 ecologic 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 efficient and 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 child 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 13 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