community-driven healthcare reform
R A T I O N A L E
F o r a n e w s t r a t e g y t o r e f o r m
o u r n a t i o n ‘ s H E A L T H c a r e ,
c o m m u n i t y b y c o m m u n i t y
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 )
” It’s better for everybody
when it gets better for everybody. “
Eleanor Roosevelt ( 1884 – 1962 )
” 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 – )
” Well-Being, when defined as a person’s highest prudential good,
represents Happiness In An Objectively Worthwhile Life. ” (70)
Neera K. Bradhwar ( 1947 – )
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 on life? If so, you’ll probably agree with the next sentence about our nation’s healthcare. The current efforts to reform our nation’s healthcare will not improve the health care offered for the Basic Healthcare Needs of every citizen. This health care is often hard to locate or difficult to use because of its cost, the travel time to arrive at its location, or the need to pass through multiple institutional and emotional “doors” to arrive at its source.
For truly lasting healthcare reform, any new nationally sanctioned strategy must promote enhanced Primary Healthcare that is “equitably available” to each citizen within the safety net of their own community. Every other developed nation of the world has a nationally sanctioned strategy to assure the equitable availability of Primary Healthcare for each of their citizens, most for a long time. 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 problems 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 offers lasting Caring Relationships as the basis for promoting Stable HEALTH For Each Citizen.
Next, please accept the concept that our Nation’s healthcare reform will also require an improvement of its social cohesion. As its most defining character, healthcare reform must collaborate with a locally-initiated investment of social capital within each community of @400,000 citizens. Each community’s local commitment to improving its own social capital asset, simultaneously by nearly 800 separate communities, may represent just too many unknowns. However, if a locally initiated and community-focused strategy to improve their own Survival Commons could represent a plausible platform for our nation’s healthcare reform, please read on.
The remainder of this Sub-Page takes about 20-30 minutes to read. It describes a plan to release the paradigm paralysis that is currently strangling our nation’s healthcare industry. A focused paradigm shift will be required to release the unfocused power and disciplined sophistication of our nation’s healthcare. To achieve this paradigm shift, a new strategy should begin by slowly building momentum. 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 Basic Healthcare Needs of each citizen. Locally originated and maintained Collective Action will be required to improve the Survival Commons, aka safety net, within each of our nation’s communities.
TWELVE BASIC CONCEPTS — LET’S BEGIN
Twelve concepts, each defined with interconnected terms, should represent the basis for any discussion about healthcare reform. Each one of these concepts has not achieved a widely affirmed basis for their precise definition, especially when defined without elements to establish their inter-connection for HEALTH. To improve our understanding and ability to implement healthcare reform, each of the concepts should be defined with precise terminology that achieves a meaningful connection among the thirteen concepts. As you will eventually perceive, these concepts represent the basis for promoting a new nationally instituted and implemented strategy, community by community, for national healthcare reform.
Alphabetically listed, the twelve concepts are CARING RELATIONSHIP, CLUSTER, COLLECTIVE ACTION, COMMUNITY, DISRUPTIVE PROCESSES, FAMILY, HEALTH, PERSON, SOCIAL CAPITAL, SOCIAL COHESION, SOCIAL DILEMMA, and SURVIVAL COMMONS. Together, they form a ‘new beginning’ to inform a reconfiguration of our nation’s strategy for healthcare reform.
C A R I N G R E L A T I O N S H I P may be defined as
^
a variably asymmetric social interaction occurring between two persons that
begins with a beneficent goal to enhance each other’s autonomy and
flourishes from a timely obligation to communicate in harmony
with warmth, acceptance, honesty, and empathy.
C L U S T E R may be defined as
^
a group of two or more components that achieves
a sustainably resilient capability
from its attributes of uniquely configured
synergy between the respective components,
affinity between the prominent components, and
conditions surrounding the components.
C O L L E C T I V E A C T I O N may be defined as
^
a Cluster of persons who collaborate with sufficient norms
of trust, cooperation, and reciprocity to define a Visioning Statement
and its Action Plan for improving the beneficence and autonomy
of their own or another Cluster’s persons that the initial Cluster
selectively delegates to one or more of the following options: itself,
representative persons from among the initial Cluster’s persons,
an institution chosen by the initial Cluster, or another Cluster.
C O M M U N I T Y may be defined as
^
a Cluster of persons who share certain uniformly identifiable attributes and
a valued awareness about their interconnected identity
that is borne out of the Cluster’s “mutually experienced events” and
each person’s association of these “events” with certain memories
of their own ecologic and cultural traditions, typically recognized
as the citizens who live within a geographically defined Municipality.
D I S R U P T I V E P R O C E S S E S may be defined for HEALTH as
^
a variably originating disturbance, as manifested by the subsequent onset
of evolving processes involving certain attributes of a person’s combined
Clusters of Human Capabilities, baseline homeostasis, and innate temperament,
that represents a destabilizing effect on the resilience of the person’s HEALTH.
F A M I L Y may be defined as
^
a Cluster of persons that:
^
A. CONFIGURES itself with a GOAL to preserve each person’s HEALTH by the steady immediacy of their daily social interactions;
^
B. INSTITUTES itself to achieve the Cluster’s GOAL during the generational cycle of its originating Independent person or persons when
1. two originating Independent persons express a lifelong commitment to sustain their Caring Relationship as affirmed by their marriage certificate OR
2. one originating Independent person, who is not married and has a Caring Relationship with a Dependent person, assumes custodial responsibility for this Dependent person as the first additional Dependent person within their Cluster;
^
C. SPONSORS safe expressions of kindness and respect by the Cluster’s persons for the other persons they encounter during the Municipal Life of their community, irrespective of any ecologic or cultural attributes possibly represented by these other persons; AND
^
D. ASSEMBLES a constellation of Family Traditions as the basis for guiding the responsibilities of the originating Independent person or persons to
1. establish their Home, typically within a community’s neighborhood, for the residential requirements of the Cluster,
2. promote Caring Relationships
a. among the Cluster’s persons and
b. between the Cluster’s persons and the persons living outside their Home who are members of either the Cluster’s Extended Family or the Cluster’s Micro Social Networks,
3. promote gatherings of the Cluster’s persons
a. for a weekly pattern of Family Mealtimes to ameliorate each person’s encounters with modest Disruptive Processes and
b. with the persons of their Extended Family to enhance the ecological and cultural character of the Cluster’s Family Traditions, especially in association with the transitional events occurring throughout the Cluster’s generational cycle,
4. promote a Personal Survival Plan for each of the Cluster’s persons by adapting the housing capabilities of their Home
a. for the general requirements of each person’s HEALTH as in “Restful SLEEP,” “Good FOOD,” “Dedicated EXERCISE” and “Mentored COURAGE” and
b. for modulating each person’s encounters with substantial Disruptive Processes,
5. accept an additional Independent person into their Home, if the additional Independent person becomes an originating Independent person through marriage with a Cluster’s sole originating Independent person OR the additional Independent person
a. has the consent of the current originating Independent person or persons beginning on or before the date of the additional Independent person’s initial residence within their Home and
b. has a written Personal Survival Plan or its next-of-kin approved equivalent that includes
i. provisions to manage the additional Independent person’s HEALTH in the event 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
ii. a notarized Will, power of attorney, and medical power of attorney, AND
6. accept an additional Dependent person into their Home, if at least one current originating Independent person has an established custodial responsibility for the Dependent person as defined
a. biologically through birth, child, or sibling OR
b. legally through adoption, guardianship, foster care, or divorce.
H E A L T H may be defined as
^
a person’s daily expression of Well-Being during their lifelong survival that is:
^
A. Enriched by the person’s coordinated synergy beginning before birth
between their baseline homeostasis and innate temperament
for modulating the person’s adaptive resilience after birth,
especially during early childhood as a Dependent person;
^
B. Nurtured by the Caring Relationships originating before birth
from within the Dependent person’s Family to enrich
the person’s search during childhood for the broadest portrayal
of their reflective-cognition Cluster of Human Capabilities and
the Caring Relationships originating after birth from within
the Extended Family and Micro Social Networks of the person’s Family
to mentor the adaptive resilience of the person’s innate temperament
during the social interactions occurring while becoming an Independent person;
^
C. Challenged by the daily encounters with modest Disruptive Processes
beginning before birth and occurring as interacting combinations and patterns
to cause reversible or irreversible and variably beneficent or maleficent effects
on the developmental resilience of the person’s combined reflective-cognition
Cluster of Human Capabilities, baseline homeostasis, and innate temperament
as ameliorated through the Caring Relationships originating from
within the person’s Family, Extended Family, and Micro Social Networks;
^
D. Matured by the episodic encounters with substantial Disruptive Processes
beginning before birth and occurring as interacting combinations and patterns
to cause reversible or irreversible and usually maleficent effects
on the resilience of the person’s combined Clusters of Human Capabilities,
baseline homeostasis, and innate temperament as mitigated
through the Personal Survival Plan of the person; AND
^
E. Sustained by the person’s generational Caring Relationships,
the 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, baseline homeostasis, and innate temperament
becomes insufficient for survival
from the person’s 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 its transformation during maternal gestation
to achieve sufficient resilience for survival at birth.
S O C I A L C A P I T A L may be defined as
^
the capability of a community to assimilate and preserve
the norms of Trust, Cooperation, and Reciprocity that are expressed
by the community’s persons for resolving the Social Dilemmas they encounter
during the daily social interactions within their community’s Municipal Life,
especially when the community’s ecologic and cultural traditions depreciate
the spontaneity and endurance of the generational Caring Relationships connecting
each person with their Family and their community’s Social Networks.
S O C I A L C O H E S I O N may be defined as
^
a broadly shared expectation among a nation’s citizens
that the persons within each others’ community are trustworthy and
that each community’s prevalence of trustworthy social interactions occurs
from the collaborative traditions involving their adjacent communities to improve
each other’s Survival Commons with sufficient investments of Social Capital.
S O C I A L D I L E M M A may be defined as
^
an encounter involving a cluster of persons
that occurs as a collective action situation for which
each of the cluster’s persons must make their own decision
as to whether they will acquire a short-term benefit for themselves OR
forgo some or all of the short-term benefit for the long-term benefit
of the entire cluster of persons participating in the encounter.
S U R V I V A L C O M M O N S may be defined as
^
the Clusters of Community Capabilities that reduce
the prevalence of Unstable HEALTH among a community’s citizens
from the unexpected or sustained occurrence of certain Disruptive Processes
WHEN these Clusters of Community Capabilities are:
^
A. Instituted by the community to “…promote the general Welfare…”
of its citizens in accord with their nation’s laws and regulations
that concurrently apply to the community’s
private and public institutions at all scales;
^
B. Enhanced by the mutually supportive social interactions occurring frequently
among the persons within their community’s Municipal Life, especially
when expressed as a safe greeting of kindness and respect by one person
to another person who responds with an appreciative gesture;
^
C. Offered by the community to each of its citizens
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 ecological and cultural environment of the community;
^
D. Promoted by the community’s volunteer citizens 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
equitable availability, ecological accessibility, just efficiency, and reliable effectiveness;
^
E. Augmented by the initiation of various Collective Action strategies
from within the community’s institutions and Social Networks
that is intended to ameliorate any “newly recognizable adversity“
affecting its resident persons from a locally prominent discontinuity
among their community’s Clusters of Community Capabilities or
their specific Benefits and Obligations, especially
if the “newly recognizable adversity“ represents an impairment
of the opportunities for equitable social mobility
for these resident persons;
^
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 associated Disruptive Processes will cause the impairment
of the capability to maintain a basic Personal Survival Plan
for a significant portion of the community’s citizens; AND
^
G. Supported by the community’s
public and private institutions at all scales and
by their Nation’s level of autonomy within the worldwide
marketplace arenas for its Resources, Knowledge, and Human Dignity.
a NEW STRATEGY
Given the heritage of our nation’s healthcare and these eleven definitions, I offer a new view of meaningful healthcare reform. This new strategy for the reform of our nation’s healthcare must continuously promote a renewal of the Survival Commons within each citizen’s community. 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 citizen within their own community. This health care should offer Caring Relationships as defined above, thoughts spanning more than 2,500 years. A community commitment to equitably promote an enduring Caring Relationship between each citizen and a Primary Physician should be the essential attribute for this new view of healthcare reform.
The eventual improvement of healthcare, community by community, will require three nationally sanctioned projects. These national projects are necessary to successfully support community-driven healthcare reform. They 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 all citizens; 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 support this obligation, each community averaging about 400,000 citizens would support the formation and functions of a Community HEALTH Forum. Nearly 800 of these Forums, nation-wide, would each be responsible for a Community HEALTH Plan to begin an annual assessment of its equitably available Primary Healthcare and the results of a monitoring process for the efficiency and effectiveness of its healthcare. The report should include the options in place to promote continuous improvement of this Primary Healthcare to qualify for HEALTH SECURITY certification. Eventually, a mature Community HEALTH Plan would also include:
- a section devoted to achieving equitably available and HEALTH SECURITY certified Primary Healthcare for each citizen as planned from among 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-focused 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; and
- a section to describe the local community’s annual review of its Master Disaster Mitigation Strategy for *) the likely occurrence of predictable disasters as a basis for mitigating, where possible, the effects of these disasters and, indirectly, of its unpredictable disasters; *) the applicable preparation in advance of and recovery efforts immediately following these disasters and *) the community’s connection to their City, County, State, and Federal governments’ disaster preparedness strategies.
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 health, 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 unpredictable events.
After a few years, the character of these Community HEALTH Plans are likely to reflect the diversity of local attributes but could eventually coalesce nationally 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 resiliency of the community’s Social Capital commitment to advance its Survival Commons would be the most profound underlying component for the success of its disaster planning benefits.
Each Community HEALTH Forum would be formed from within the locally prominent, community-benefit stakeholders. As ADVOCATES within the over-all umbrella of NATIONAL HEALTH, each Forum would participate along with the other nearly 800 Community HEALTH Forums to pursue the collaborative options among their healthcare institutions already in place. A specific obligation for each Forum would engage and initiate “trust, cooperation and reciprocity” among their existing community institutions. Beginning more than 500 years ago, the enduring level of locally mobilized volunteerism may be our nation’s most important heritage for sustaining our nation’s worldwide autonomy and now for the continuous improvement of our nation’s HEALTH.
MISSION TO THE MOON
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.”
Ten years after starting this newly considered “moon-shot,” I propose three very specific, National GOALs for healthcare reform: 1) reduce the 2018 spending for our nation’s healthcare from 18.0% to 13.0% of our nation’s economy; 2) reduce the annual incidence of women dying from a pregnancy in 2016 from 24.6 to 5.0 deaths per 100,000 live births, i.e., its maternity mortality ratio; and 3) eventual ratification by all States of a Congressional Charter to establish a new nationally constituted, semi-autonomous institution to guide this reform. Over ten years, these GOALs beginning in 2020 and ending in 2030 would: 1) reduce the annual health spending within our nation’s GDP by 28%, 2) reduce the number of women dying with a pregnancy by 70%, and 3) achieve ratification by all 50 States of a Congressional Charter for their participation in new semi-autonomous institution, NATIONAL HEALTH.
Reducing the cost of our nation’s healthcare will be especially important for our nation to retain its autonomy within the market-place arenas for the world’s Resources as well as for its Knowledge and Human Dignity. Between 2011 and 2021, 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 2014, their nation was no longer able to arrange loans to support the deficits of its national government without dramatic changes in its governance.
For 2018, total health spending for our nation’s healthcare was $3.56 Trillion. It represented 17.8% of our national economy. 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 2018 could be estimated as the difference between 13.0% and 17.8% of our nation’s economy in 2018. This excess health spending for our nation’s healthcare in 2017 would have been $1.05 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, representing $452 Billion of its excess cost in 2018. Most importantly, this $452 Billion represented 58% of our Federal deficit of $799 Billion in 2018. The excess cost of our nation’s healthcare currently represents the largest contribution to the 2018 deficit of our nation’s Federal government. Furthermore, there is absolutely no evidence that the current over-all strategy for healthcare reform will do anything to improve the overall efficiency and effectiveness of our nation’s healthcare.
As for its effectiveness, our nation’s maternal mortality ratio (MMR) is the most representative measure of its effectiveness. The MMR number represents the number of women within our nation who died during a year from most causes related to a pregnancy per 100,000 living births. The best analysis for the national statistics was most recently published in September of 2016 (60) for annual data that go back to 2000. This same publication also reported state by state data for 2005-2014. For perspective, there were 3,978,497 live births nationally in 2015.
The USA is the only developed nation in the world that has had a worsening maternal mortality ratio for 30+ years. And, our Nation’s MMR ranked 42nd worst among the 51 advanced developed nations of the world as reported by the United Nations for 2015. Based on a current analysis of the marginally different statistics, at least 700 women died during 2016 in the USA related to a pregnancy who would still be alive if they had lived in Iceland, Finland, Poland, Sweden, Austria, Italy, Czech Republic, Greece, Kuwait OR Norway when their pregnancy started. These 10 of the 51 advanced, developed nations had an average MMR of 3.8 according to the U.N. report of 2015.
Finally, the last data set for MMR levels, state by state, listed the average of each state for the years of 2005 through 2014, nationally it was 11.3 . The best 5 states had an average MMR of 7.2 . One of these best 5 states was Alaska. If Alaska with all of its geologic, seasonal and Alaskan Native adversities could still achieve this result, shouldn’t it be possible for all the other 44 States and the District of Columbia to work toward that goal?
Beginning today, “lift-off” for NATIONAL HEALTH could be 6 months away. Our nation’s autonomy within the world-wide community is at stake. Established by a Congressional Charter for the benefit of our nation’s future, each citizen would eventually recognize the V I S I O N of the new institution by its name. I propose the following envisioning statement for NATIONAL HEALTH:
V I S I O N – Stable HEALTH For Each Citizen
^
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
GETTING STARTED
To understand the basic dimensions for the future of healthcare reform, I begin with 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 have come here from foreign lands? To be sure, many passions have motivated the men and women who have chosen, and continue to choose, emigration 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 speech as well as 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, coercive government and, frequently, large-scale military violence. According to the NEWSEUM in 2014, only 9% of the world-wide population, who live outside of the USA, are citizens of a nation with our First Amendment rights.
The third passion that motivated immigrants has been, and still is, the chance to start a new way of life. Starting 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 all persons. Other immigrants have come to our nation only to serve their own predominantly self-centered economic or social values. And, finally, the early immigrants forced our Native 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 a 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 Congregational church community who had supported their commitment.
Despite the reasons for immigration, successful survival in North America required self-discipline, hard work, and altruism – a desire to help others. For 500 years, this dedication to individual survival has been associated with an expectation that each community would function better if its citizens survived primarily on their own 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.
PARADIGM SHIFT — historical origin
Between 1850 and 1900, the origins of anesthesia and infection control began to evolve. This meant that the benefits of surgery needed 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, now more appropriately labeled as “nursing homes.” Most of these were community established through county and city levels of government or religious institutions. With the evolution of surgery, some of these early nursing homes adapted to eventually become modern-day hospitals.
Most importantly, the early and eventually profound evolution of life-saving healthcare beyond the confines of a person’s home removed a powerful focus on Family Traditions to empower the mutually shared commitments within a Family to care for each other. Originating slowly during the aftermath of the Civil war ending in 1865, newly constructed hospitals 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 citizens, the ecologic character of each person’s HEALTH became exposed to many newly evolving changes, e.g., travel, communication, urbanization, and industrialization. A continuing cycle of violence, world-wide and neighborhood by neighborhood, has evolved since the end of WWII in 1945. And amid the cultural 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 supporting each person during episodes of Unstable HEALTH, especially a pregnancy.
All of this has led to a diminished commitment within each community to sustain the Stable HEALTH of its citizens through its Survival Commons. Beginning in 1969, the Disruptive Processes that represent the causes of Unstable HEALTH became 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 almost any definition.
Disruptive Processes refers to the root causes underlying the unstable expression of a person’s survival. This could represent the obvious physical injuries of broken bones and head injuries. But, it also refers to pneumonia, emotional stress, food insecurity, lack of sleep or anything else that in combination decreases the stability of a person’s HEALTH.
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 citizen. This change in the last 50 years means that self-discipline, hard work, and altruism no longer guarantee that health care is equitably available for the Basic Healthcare Needs of each citizen, even for the citizens who have achieved economic success. Inadequately available health care for Basic Healthcare Needs can be especially profound *) for any woman prior to and during a pregnancy and *) for any citizen 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 and ecologically accessible by each citizen within every community. The effect of this deficiency has led to severe problems within our healthcare industry, as in its preventable maternal deaths.
The imbalance is the partial result of an inadequate level of financial capital for the Basic Healthcare Needs of each citizen as compared to the financial capital that is available for their Complex Healthcare Needs. It is not the fault of one citizen or a group of citizens. It began to occur, more prominently, after Congress authorized Medicare and Medicaid in 1965. Between 1960 and 2016, the portion of our nation’s economy allocated to healthcare has more than tripled. Unfortunately, the flow of these resources preferentially into 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 largely medical school, affiliated hospitals. The institutional co-dependency is also a root-cause of the Paradigm Paralysis afflicting our nation’s healthcare industry, one of many.
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 2009, this industry has will require 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 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 for each citizen within their own community.
Ultimately, our nation’s healthcare industry must begin a tradition to establish its capacity to re-energize a local ‘collaborative’ heritage within each community. This heritage would sustain a nation-wide, community by community tradition for recognizing each community’s obligation to promote Stable HEALTH for each of their citizens. The new strategy should also focus on the HEALTH of its citizens with special needs, especially every child and their mother. Thirty years from now, our nation’s autonomy within the world-wide community will depend on the strength of each community’s Survival Commons that will be necessary to foster our nation’s caring and learning generations of citizens, year after year. A newly enriched definition of HEALTH helps to explain this assertion. It is one of the 11 new definitions listed above.
“GOVERNING THE COMMONS”
Because of its profound inefficiency, our healthcare industry is no longer affordable within our nation’s economy. A “Tragedy of the Commons” has occurred. (30) The traditions of our national heritage have led to this crisis. Exploring the basis for remodeling these traditions is the central theme for NATIONAL HEALTH. The TRADITIONS Page and its Sub-Pages explore this theme in greater detail. They attempt to explain why the problems are so difficult to define and so resistant to implementing any solutions originating from within our nation’s healthcare industry. An over-all strategy has not been consolidated by the mainstream of our nation’s healthcare industry.
Professor Elinor Ostrom points the way with her studies described in nine books published between 1990 and 2010. “Governing the Commons” (31) 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. Her studies, along with the research of numerous colleagues, have defined the Design Principles for ensuring successful governance by a group of institutions with a responsibility to preserve a common-pool resource. In 2009, Professor Ostrom received a Nobel Prize in economics for her research.
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 for this Blog covers primarily the last 70 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 Initiative Page and its Sub-Pages for the new institution, NATIONAL HEALTH.
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 2010. 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. Their state’s Public Health Department 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 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. The balance of improving the daily HEALTH of individual citizens must be balanced by an evolving continuum of ‘healthcare’ over time and how it fits together for the seamless ‘health care’ needs of each citizen. 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 Page and its Sub-Pages analyze the essential traditions of our nation’s healthcare. Five of the Sub-Pages propose a solution for specific root-causes within the Paradigm Paralysis of our nation’s healthcare. Based on this analysis, the Initiative Page and its Sub-Pages describe a new institution, NATIONAL HEALTH, Chartered by Congress. See the OVERVIEW Page for further 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 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 above represents the title of a book written by Robert L. Heilbroner. (61) 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 continue a sense of our nation’s heritage over the last 500 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 as the Civil War ended, the 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 the locally expressible needs for Social Cohesion already exists 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 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 with a pregnancy, from 24.6 to 4.9 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.
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 market place 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 basis for improving the HEALTH of each community’s citizens.
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 2016. It represents an increase of 5.0% annually most easily explained by Parkinson’s Law. Using the Design Principles defined by ‘s Elinor Ostrom and validated by many colleagues, NATIONAL HEALTH could achieve the widely supported authority necessary to implement the strategies required at the national, regional and local levels for healthcare reform for a national Federal expense 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 citizen.
To begin true healthcare reform, it should be locally implemented and nationally promoted, community by community. 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 ‘Stable HEALTH For Each Citizen’ through communities of action.
